T^F^ 



O"^".^ 



' 8 ^ 



s o' 






,^^ ^'^.^ 



f . . ^^ 

y '^ "" --- ' '' 






!.0°. 



"^. 



^ 



% <i' 



"<.. 















'JO. 



.v<>^. 






•,^ 













v^^ ^'^^ 



-.-ft t- o ta, * 'p. 



■<^ 



• 0. \ -^ 



#^ 









<t.. 



*«.. 






i-^^-^ 



// ^ 






vO 
























7 /- 



^' G 







c°' .o 






/■ 












'. -'r 






•■.s..<S^ 






^-^.^'^ 









.S<i 



"oo^ 






\,^ 









>-^. 



_^,-\'' 



^/- '' 






A-^ 



<^^' 
x^'^ 



V-- 



.^\\ 



<,. <^^' 



^^^'' 



o 






A TEXT-BOOK 



OF 



FRACTURES AND DISLOCATIONS 



WITH SPECIAL REFERENCE TO THEIR PATHOLOGY 
DIAGNOSIS AND TREATMENT 



BY 

KELLOGG SPEED, S.B., M.D., F.A.C.S. 

ASSOCIATE IM SURGERY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL; ASSOCIATE SURGEON 

MERCY hospital; ATTENDING SURGEON, COOK COUNTY AND PROVIDENT 

HOSPITALS, CHICAGO, ILL. 



ILLUSTRATED WITH 656 ENGRAVINGS 




LP]A & FEBIGER 

PHILADELPHIA AND NEW YORK 
1916 



•St 



Entered according to the Act of Congress, in the year 1916, by 

' LEA & FEBIGER, 
In the Office of the Librarian of Congress. All rights reserved. 



Gjr* .. 




m -3 1916 

©C1.A427937 



TO 

EDWARD WYLLYS ANDREWS, A.M., M.D., F.A.C.S. 

GENTLEMAN, MASTER SURGEON AND FRIEND 

THIS BOOK 

IS RESPECTFULLY DEDICATED BY 

THE AUTHOR 



PREFACE 



Ix the preparation of this work the author has carefully culled from 
the literature the information which seemed most helpful and with it 
has combined his own ideas and experience in order to cover the 
field and to present a clear understanding of this important branch of 
surgery. ]Much of the clinical and all of the statistical material has 
been obtained at the Cook County Hospital, Chicago. Although 
the author has personally performed the labor of writing the text and 
gathering the illustrations, for all of which he alone is responsible, 
he has been fortunate in receiving the helpful cooperation of his 
colleagues in the hospitals with which he is connected and of members 
of the Chicago Surgical Society. He wishes here to express his 
appreciation of their kindness if at any place in the text he has failed 
to make more specific acknowledgment. 

It has come to be appreciated in all branches of medical teaching 
and research that a basic knowledge of pathology is of prime impor- 
tance, so it is believed that clear conception of osseous injuries and 
their repair is essential to an understanding of fractures. Better 
treatment results. For this reason the author has selected examples 
of different types of usual fracture pathology and endeavored to bring 
them before the reader's eye by means of line drawings which illus- 
trate the essential points. Every illustration of this character is a 
careful reproduction of a tracing made from a Roentgenogram of an 
actual case. The Artist, Mr. Streedain, and the author have w^orked 
for nearly two years preparing these drawings, checking and rechecking 
each one until it conveyed the author's conception of the lesion. No 
one can read all roentgenograms with positive assurance. The author's 
obligations to Dr. Blaine, Roentgenologist to the Cook County Hos- 
pital, for his friendly cooperation in this part of the work are gratefully 
recorded. The Artist has attempted to differentiate the shadows of 
bones more distant from the observer by lighter lines, and where two 
shadows overlap has indicated the one more remote by dotted lines. 
Cutaneous landmarks, lines of incisions with skin clips and plastt^r 
dressings have been occasionally indicated for obvious reasons. 



vi PREFACE 

It has seemed unwise to cumber the pages with statistical charts 
and tables recording all cases of fractures studied by the author; 
but he has not failed to incorporate freely in the text deductions 
from many such tables which have been accurately compiled for his 
private use. The nomenclature employed accords with that used in 
the Howden edition of Gray's Anatomy. 

The author wishes to thank the Publishers for making the book 

possible. He is also under obligations to his various House Surgeons 

and to those who have helped in the mechanical preparation of the 

text. Dr. J. J. Andrews and D. L. have aided greatly by friendly 

criticism. 

K. S. 
Chicago, III., 1916. 



CONTENTS. 



CHAPTER I. 
Bone 17 

CHAPTER II. 
Etiology axd Mechanism of Fracture 35 

CHAPTER III. 
Pathology of Fracture 53 

CHAPTER IV. . 
Symptoms, Signs, and Diagnosis of Fracture 91 

CHAPTER V. 

Treatment of Fractures 97 

CHAPTER VI. 
Operative Treatment of Open and Closed Fractures 123 

CHAPTER VII. 
Dislocations 158 

CHAPTER VIII. 

Fractures of the Skull 184 

CHAPTER IX. 

Fractures of the Bones of the Face 214 

CHAPTER X. 
Fractures and Dislocations of the Vertebra*: 243 

CHAPTER XI. 

Fractures and Dislocations of the Clavicle 286 

CHAPTER XII. 

Fractures of the Scapula 322 

CHAPTER XIII. 
Fractures and Dislocations of the Ribs and Co.stal Cartilages 331 



viii CONTENTS 

CHAPTER XIV. 

Fractures and Dislocations of the Hyoid Bone and Sternum . 343 

CHAPTER XV. 
Fracture of the Humerus 352 

CHAPTER XVI. 
Dislocations of the Shoulder 414 

CHAPTER XVII. 

Fracture of the Forearm Bones 441 

CHAPTER XVIII. 

Dislocations of the Elbow . . . '. 488 

CHAPTER XIX. 
Fractures of the Carpal and Metacarpal Bones and Phalanges . 517 

CHAPTER XX. 

Dislocations of the Wrist, Hand and Fingers 537 

CHAPTER XXI. 

Fractures and Dislocations of the Pelvis 570 

CHAPTER XXII. 

Fractures of the Femur ". 589 

CHAPTER XXIII. 
Dislocations of the Hip 070 

CHAPTER XXIV. 

Fracture and Dislocations of the Patella G97 

CHAPTER XXV. 

Fracture of the Bones of the Leg ... 733 

CHAPTER XXVI. 

Dislocations of the Knee 797 

CHAPTER XXVII. 

Fractures of the Calcaneus (Os Calcis) 813 

CHAPTER XXVIII. 

Ankle and Foot Dislocations 839 



FRACTUKES AND DISLOCATIONS. 



CHAPTER I 
BONE. 



Physiology and Physics — Regeneration — Callus Formation — Callus in Joint Fractures — 
Effects on Callus of Early Motion, Massage, and Foreign Bodies — Bone Trans- 
plantation and Fate of Transplants — Bone Repair in Open Fractures and Post- 
operatively — Clinical Course of Fracture. 

Fractures and dislocations deal primarily with bone, and the 
student and practitioner should have intimate knowledge of the 
details of osseous gro^^i:h and structures. This chapter aims to deal 
with the general questions involving bone, largely from a practical 
and clinical standpoint, because elementary facts concerning bone 
and its repair become distorted when practical application to fracture 
is needed. 

x\natomical text-books give information in regard to the formation 
of bone, its deposition in cartilage and membrane, and the present 
\\Titer has no intention of reiterating. Osseous tissue, the hardest 
tissue of the human body, is not to be considered as an inert framework 
on which other important organs and tissues are draped. It possesses 
elasticity and toughness — that is, power to resist stress and strain — 
and is consequently governed by the physical laAvs of elastic bodies 
subject to these forces. Fortunately for animals, and especially for 
men, bones are also influenced by other factors which govern their 
appearance, strength, power of recuperation, and regeneration. An 
analysis from the standpoint of composition, with bone considered as 
a physical combination of substances, demonstrates that the earthy 
or hard properties are furnished by calcium phosphate, carbonate, 
and fluoride, with the addition of some magnesium phosphate. These 
salts compose about (Hi per cent, of the total bone weight. Adolescent 
bones contain a smaller percentage of salts, senile bones, a greater per- 
centage. The calcium balance concerns all the skeletal tissues in the 
builfling-up and tearing-down processes. There is probably a con- 
tinuous flow of calcium salts both to and from the bone, the amount 
dependent on the avaihible suj)ply in the food intake and on the 
metabolic ])rocesses, a matter of such intricate mechanism that it is 
not thoroughly unrlerstood. Fnder ordinary conditions of food and 
n.etabolism the supply is sufficient to meet all demands; when the 



18 BOME 

diet is deprived of calcium salts there is absorption from the bones. 
This loss by the bones first affects those wfiich can spare calcium best 
without affecting their tensile strength, namely, the sternum, skull, 
ribs, etc. Under some conditions the amount of ingested calcium is 
by no means a measure of that used in bone reconstruction, because 
other tissues demand these salts. In rickets and osteomalacia there 
is probably such a diversion to other structures, and perversions with 
skeletal deformities exist in diseases of the pituitary body and disease 
or congenital absence of the thyroid or thymus. 

While we accept this information as all important in its bearing on 
the rigidity of osseous material, we must not lose sight of the fact 
that bone is a living and growing tissue. It varies in size and shape 
from time to time; it is built up and torn down much as are the skin 
and epithelial surfaces which are constantly undergoing repair; and 
it is shaped by the plastic power of growth and force, as are the soft 
tissues. Wolff's law states the idea thus: the shape of bones is deter- 
mined by conditions of reactions of bones in structure and shape to 
the body weight and to stress and strain of muscular action.^ 

Life and growth of bone are provided for by its division into three 
parts: the covering or periosteum, the compact tissue or dense ivory- 
like substance, and the cancellous tissue or softer part found within 
the compact. Blood supply is rich, furnished by the periosteum, with 
its vessels penetrating into the compacta and cancellous tissue, and 
the nutrient and epiphyseal arteries which supply the softer content 
within the hard outer layer. Blood supply is of the greatest impor- 
tance in bone regeneration and growth, as it is in any tissue, another 
factor too frequently overlooked. There are also nerves and lym- 
phatics in bone, delicate and important structures which perform 
their functions inside the hard covering about them. These functions 
are easily terminated when the covering is greatly disturbed, as in 
fracture or other injuries. 

It has been determined that the proportion of earthy salts in the 
bone matrix is a sensitive indication of the life of the bone, that is, 
of its age or condition of health. W^hen bone is diseased or injured 
or deprived of its normal function of stress and strain from weight- 
bearing and muscular action, an atrophy develops within it. The 
proportion of the salts in its composition is disturbed, and early evi- 
dence of this disturbance is found in the character of the shadow cast 
on the sensitized plate when an exposure is made to the Roentgen rays. 
Corson^ has stated that the Roentgen-ray shadow of an element is 
distinctly proportional to its atomic weight. Calcium with an atomic 
weight of 40 makes a denser shadow than magnesium, weight 24, 
and because the latter represents only a small percentage of the 
earthy salts, the main role in shadow density is played by the calcium 
salts. The best example of this truth lies in the fact that recent callus 
casts no shadow. No calcifying salts have been deposited. Bone 

> Tubby, Brit. Med. Jour., 1908, vii, 25. 2 Ann. Surg., li, 289. 



REGENERATION OF BONE 19 

atrophy may be the result of a neurotrophic process, or a senile osteo- 
porosis, or of bone cysts affecting small areas, or the hypertrophic 
syphilitic conditions which leave pits of ulcerating gummatous areas. 
It also occurs after muscular trauma and inactivity, poliomyelitis or 
the muscular dystrophies, cerebral palsies, etc. Sensitive bone may 
show atrophy after nerve injury which involves itself directly or its 
surrounding soft parts. This pathological fact is of practical bearing 
in some cases of non-union, or in refracture following clean operative 
fixation, or in removal of tibial crests for autogenous splints, which 
may be the result of such nerve disturbance.^ (See Chapter on 
Operative Treatment.) 

Cancellous and compact tissue are much alike, the former being 
more porous. When it is necessary in body economy that great 
weight and much stress should be sustained, a bone is composed of 
more elastic cancellous tissue and less friable and rigid compact tissue. 
The calcaneus and vertebrse are excellent examples. They have a 
mere shell of compact tissue about them. Great rigidity and stiffness 
needed in the limbs is shown by the increased amount of the compact 
tissue in the shafts of the femur, tibia, humerus, and forearm bones. 
A vertically sawed section of the tibia shows that the direction of the 
important bone lamellae is vertical. In the head of the bone these 
spread out laterally in a direction to take up the strain of weight-bear- 
ing. The direction of the main lamellae coincides also with the 
direction in which muscular strain takes effect. Dixon^ states that 
the cancellous ends of long bones, in spite of their apparent delicate 
structure, will resist enormous pressure if the pressure is applied in 
the normal direction of body weight or muscle strain. (See figure 
illustrating structure of the calcaneus.) 

REGENERATION OF BONE. 

How bone grows is an undecided point in pathology. The experi- 
mental and clinical observations touching it are of interest here only 
inasmuch as they cover regeneration after traumatic separation or 
fracture and its treatment. In the newborn the ends of the long bones 
entering into joints are round and smooth and separated from each 
other by cartilage. As age advances, calcium salts are deposited in 
these cartilaginous areas and cast a shadow in the roentgenogram. 
The new shadow-casting areas are the epiphyses, the original shaft 
of the bone the diaphyses, and the remaining clear cartilaginous areas 
between the two are the epiphyseal lines. 

If a sifted resume of the large amount of recent literature on this 
subject is to be arrived at, it is necessary to consult many authors 

1 Die Roentgen Strahlen in Dienste der Neurologic, Fiirnrohr, Berlin, 190G; editorial, 
Jour. Am. Med, Assn., November 21, 1914; McCrudden, Tr. XVth International 
Congress on Hygiene, etc., 1913, vol. xi. Part II, p. 424; and Deutsch. Archiv f. klin. 
Med., Band ex, Heft 1 und 2, p. 90. 

2 Manual of Human Osteology. 



20 BONE 

and recall some of the physical facts in the preceding paragraphs. 
Little has been said about the periosteum previously, because around 
this tissue has been waged the war concerning growth of bone, callus 
formation, delayed and non-union, and necrosis. It must be recalled 
briefly that the periosteum is derived from fetal mesoderm and mesen- 
chyme, which later become connective tissue. The derivations of this 
connective tissue are closely allied; they are represented by cartilage, 
ligaments, tendons, fasciae, and bone, the last of which develops 
from fibrous tissue as intramembranous bone, or from cartilage as 
intracartilaginous bone. When the fibrous or cartilaginous tissue 
becomes bone, cells known as osteoblasts or chondroblasts deposit 
calcium salts in the fibrous matrix and a bony network results. This 
network advances in all directions, and later the cells bordering the 
newly formed osseous tissue condense to make a membrane about it. 
This is periosteum, and by the time it has become a distinct membrane 
there is formed beneath it a layer of osteoblasts which proceed to the 
deposition of the compact bone. The process in cartilage is similar, 
starting from ossification centres, the perichondrium assuming the 
function of the periosteum. 

Full-developed periosteum is a fibrous membrane closely adhering 
to the bone circumference except at the cartilaginous ends. The 
fibers of Sharpey, or fibrous trabeculse, penetrate at right angles from 
the periosteum into the compact bone. There are also penetrating 
bloodvessels branching from the periosteal supply into the cancellous 
tissue. Histologically, there is no distinct line of separation of the 
periosteum from the compacta.^ When an operator peels the perios- 
teum or strips it with instruments, lines of cleavage are found, close 
study of which reveals different depths of separation. During a grow- 
ing stage of bone the periosteum contains the osteoblasts in distinct 
cellular rows surrounded by a fine network of bloodvessels and fibrils. 
When adult bone condition is attained, these osteoblasts in the peri- 
osseous layer disappear for the most part, and only a few cells remain 
in an inactive state, their number and physiological activity being 
governed by the functional and irritative demands of the bone. Con- 
sequently this fibrous covering of the bone has three layers : the outer 
tough fibrous tissue which is highly vascularized, a middle elastic 
layer of varying thickness which is closely adherent to the compact 
bone, and enclosed between it and the compacta the third or perios- 
seous layer of fibrils and small cells. This third layer in adult bones 
is very narrow; in growing bones it is thicker and can be divided into 
two cellular layers, an outer with flattened nuclei, and an inner with 
oval or round nuclei of younger cells. There is no distinct and con- 
stant line of cleavage from the compacta. Removal of the periosteum 
by sharp strokes of a periosteotome peels off a thinner layer of tissue 
than painstaking slow reflection of the membrane. This fact may 
account for the great variations in experimental results of different 

' Smith, Surg,, Gynec. and Obst., No. 5, vol. xv, 550. 



REGENERATION OF BONE 21 

obseners, because the periosteum must be a varyiug structure, and 
its removal would not strike the same level of cells or coutain the same 
proportion of dormant osteoblasts on any two occasions. The age of 
the bone and its stage of reaction to growth and irritation of metabolic 
products (alcohol), the amount of blood supply and fibrin present, 
the mechanical stimuli and destruction, are all variable factors which 
cause a divergence of experimental results. 

Cartilage regenerates largely from the perichondrium, preformed 
cartilage taking no active part in the new growth.^ IVIoore and Cor- 
bett- say that cutting the nutrient artery prevents formation of 
periosteal bridge, and as this artery supplies medullary bone, they 
would conclude that medullary bone is responsible for the s.ubperios- 
teal bridge. 

Gallic and Robertson^ agree with Macewen."^ 

It must be conceded that the osteogenetic cell§ of the periosteum, 
and in a smaller degree the endosteum, take a very active and earl}^ 
part in the regeneration of bone. Later a limited regeneration may 
follow from the compact or medullary portions. This proliferation 
is in part at least cartilaginous; it later becomes bony; and there may 
be a great difference in the relative amount of bone and cartilage 
formed at different periods, depending on the factors mentioned, 
namely, age, presence or absence of blood-clot and blood supply, 
nerve, periosteal and mechanical injury, and, according to some experi- 
menters, the amount of tissue to be regenerated. I believe the last 
makes little difference, if there is an active healthy proliferative 
process; it does take a long time to produce solid bone transversely, 
but the whole shaft of a long bone like the humerus may be regen- 
erated in the longitudinal axis in four weeks if removed subperiosteally. 
This removal I have performed on human beings, the indication being 
an acute infection. Growing conditions depend also on the force 
present, and the specific character of the cells predetermine the charac- 
ter of tissue to be formed. Experimental work demonstrates different 
results concerning the regeneration of bone, possibly for the reasons 
given previously. Some results show that there is first an active 
proliferation of the osteoblasts in the third periosteal layer to form 
cartilage, which is then rapidly transformed into bone. Regenerated 
cartilage continues to grow as cartilage, rarely becoming bone. Other 
results show that the bone is formed outside of the cartilage and 

' Haas, Surg., Gynec. and Obst., xix, No. 5, also ibid., xvii, 164; Axhausen, Arch. f. 
klin. Chir., xcix, 1; Davis, Bull. Johns Hopkins Hosp., xxiv, 164; Mallesta, Virchows 
Arch. f. path. Anat., Berlin, 1906, clxxxiv, 12.3; K. von Korff, Arch. f. mikr. Anat., 1914, 
Ixxxiv, 26.3, on histological development of cartilage; Mayer and Wehner, Arch. f. klin. 
Chir., 1914, ciii, 7.32; Ortho. Surg., 1914, p. 213; Hawley, ibid., p. 245. 

2 Tr. Western Surg. Assn., 1913. 

' Canad. Med. Assn. Jour., iv, 33. 

'• Salvetti, Deutsch. Ztschr. f. Chir., cxxviii, 130, Influences of X-rays on Callus; 
Davis, Ann. Surg., Iv, 781; Wilensky, Am. Jour. Surg., vol. xxviii, No. 2; Murphy, Surg., 
Gynec. and Obst., 1913, xvi, 493; Jour. Am. Med. Assn., Iviii, 1094; Maccwen, Growth 
of Bone, 1912; McWilliams, Surg., Gynec. and Ob.st., 1914, p. 159; Jour. Am. Med. Assn., 
1914, Ixii, .346. 



22 BONE 

gradually replaces it, using it as a framework. Newly regenerated 
bone is cancellous; later the osteoblasts in its spaces are arranged in 
concentric layers like the Haversian systems and are included as 
bone corpuscles.^ The i)eriosteinn and perichondrium take analogous 
parts in new tissue formation, and the osteoblasts tend to revert to 
the chondroblastic type, and when cartilage regenerates its cells tend 
to revert to a connective-tissue type. 

To understand fracture, its course, pathology, and the latest devel- 
opment of treatment, we must know these conditions and also the 
normal manner of callus formation, the influence of motion and unwise 
early use, and of the insertion of foreign bodies or autogenous splints. 
The fate of bone transplanted into soft parts does not interest us 
here. It is undoubtedly gradually absorbed, because it has absolutely 
no functional position to fill,^ and comes to a natural death in accord- 
ance with Wolff's law. 

Development of bone is of extreme importance, inasmuch as after 
solution of bone continuity the fragments must be welded and 
cemented together to reestablish function in the injured part. This 
is accomplished by callus. 

Callus Formation. — -For illustration let us consider a long bone. 
When it is broken the line of fracture is rarely straight, but is jagged 
or very irregular, and may include spicules and small loose pieces 
of osseous tissue between the main fragments. Blood and nerve 
supply are interfered with, there is a hemorrhagic extravasation, and 
a clotted mass fills up the space created. The periosteum is torn. 
Oilier first made clinical note of this fact, but we know now in light of 
frequent open operations and roentgenographic evidence that this 
membrane is rarely ruptured completely. It may be stripped up for 
some distance, or lacerated severely in part of its circumference, but 
never entirely destroyed. Its quality. of elasticity often saves its 
continuity. Comminuted fragments of underlying compact bone may 
be completely separated, but remain attached to the untorn perios- 
teum. A good reposition of alignment in such a case, encased in the 
guiding vaginal periosteum, would lead to a happy cementing in place 
with a similarly good functional result. If, however, the periosteum 
is torn from these fragments, they lose blood supply and may necrose 
in part. This necrosis takes place in the ends of fragments after all 
fractures, and is of intense importance. A function of exclusion is 
also assigned to the periosteum; that is, it holds out of the way the 
intrusion of the omnipresent connective tissue regenerating in the 
surrounding soft parts, which would interfere with early bone healing. 

Displacement, which removes the fracture ends from contact, 
usually strips up the periosteum and leaves a bridge joining them. 
This bridge is of importance because, as we have seen, it contains 
osteoblastic cells capable of regeneration, and a connecting link of 
tissue potentially able to form bone still persists between fragments. 

1 Gray's Anatomy, Howden edition, p. 59. 

2 Phemister, Surg., Gynec. and Obst., No. 3, xix, 303. 



REGEXERATIOX OF BOXE 23 

The effusion of blood from bone, periosteum, and muscles at the frac- 
ture site is absorbed in a few days, and there is a multiplication of 
small round cells which cause swelling and edema. A viscid, gelatinous, 
dark-colored fluid mass then exists aroiuid the fracture, which is of 
practical help in guiding the surgeon to the exact site when he is oper- 
ating through heavy muscles. The periosteum becomes h^-peremic 
and thickened, and proliferation of the dormant osteoblasts begins. 
A soft, whitish, bulbous swelling, which is symmetrical in shape, 
unites the two fractured bone ends, if there is little lateral displace- 
ment. This can be palpated in many bones, even in the femur, inside 
of twelve or fourteen days. Bone regeneration also takes place slowly 
from the compact and cancellous tissues and beneath or along the 
periosteal bridges in the effused blood. The blood-clot may be too 
extensive, and instead of being a help in bone repair may be so large 
and cause so much obstruction peripherally that it obstructs the 
general circulation and chokes the lymphatics. This condition would 
add to the task of bone repair, which is best and quickest performed 
in the face of accurate approximation and a minimum amount of 
coagulated blood. 

The compact and cancellous surface ends of the fragments become 
necrotic after fracture on account of trauma and loss of blood supply. 
For that reason regeneration from these areas is slow, being preceded 
by an absorption of this necrotic tissue and creeping proliferation out 
into it of the new islands of bone from the live Haversian canals beyond 
it. The mtervening necrotic tissue is slowly replaced by a process of 
rarefying osteitis, which removes the bone tissue by first making it 
spongy and cancellous. 

The most important element in fracture repair is the absorption of 
extra vasated blood and the layer of necrotic bone, followed by a reestab- 
lishment of vascular conununication between the fragments. This 
comes from the regenerating and budding vessels in the various bone 
elements and the erection of new Haversian colimms following on 
the capillary network. ^Nloore and Corbett in their study of the 
function of the periosteum showed experimentally that cutting of 
the nutrient artery in rabbits prevented the formation of the perios- 
teal bridge after fracture. Because this artery supplies medullary 
bone, they are inclined to believe that it, and not periosteum, is 
responsible for the periosteal bridge. 

As previously stated there is a rarefying osteitis which accompanies 
this process; that is, a withdrawal of calciimi not only in the imme- 
fliate fracture area, but over the body in general. This is probably 
an adaptive process helping the focal efforts of regeneration through 
some general stimulative process, and through softening the tissues 
promoting freer vascular gro\\i:h, the calcium being replaced later 
when bony repair has been accomplished. When necrotic tissue is 
organized by the granulations, the productive efforts of the under- 
lying active osteoblasts send projections into them, and new bone 
with later calcification into permanent tissue forms. Usually this 



24 BONE 

new bone plugs the medullary canal completely, and, after the pro- 
visional callus, thrown out by the periosseous layer and endosteum, 
has shrunken and permanent union is established, the medullary cavity 
is reestablished by a further absorption of the blocking tissues. Where 
the displacement is greater, each division of the bone tends to unite 
with its separated homologous part. If the union is angular, it may be 
very thick. When there is lateral separation, the callus attempts 
to pass in the shortest direction between the ends, taking an oblique 
angle. Laceration of the periosteum with infolding or loss of con- 
tinuity precludes the formation of this earl}^ callus. There is a pro- 
liferative reaction in the torn periosteal stumps and in the surrounding 
muscle or connective-tissue layers, but progress is slower and atypical 
in form. This is called the provisional callus and is cartilaginous and 
soft in character. Centres of ossification appear and later the whole 
mass becomes bony. 

Bone fragments of various sizes, when remaining attached to the 
periosteum and blood supply, are often moulded in with the process 
of callus formation and are of assistance in filling in gaps and acting 
as centres of regeneration. If they are deprived of circulation they 
undoubtedly become necrotic, though some peripheral cells may 
survive if they are bathed in sufficient serum to maintain Hfe. These 
dead fragments may cause irritation and delay bone union, or on the 
other hand, may, like an osseous splint, act as a framework for the 
new capillary and osseous growth and aid in union. 

Davis^ believes that the provisional callus may not be important 
in union. He cited a case in which he cut down on the fracture seven 
weeks after wiring and found nothing on the outside of the bone in 
the shape of provisional callus, though there was firm bony union. 
This w^as probably an exact anatomical reposition with no periosteal 
laceration. 

The effect of Roentgen rays on closed fractures has been studied 
experimentally on rabbits.^ A daily exposure of ten minutes, 120 
amperes at a distance of 30 cm., promoted a quick production of 
callus, but a slow deposit of calcium salts. FrankeP applied stimulat- 
ing doses of the Roentgen rays in cases of old unconsolidated fracture, 
and his results confirm the value of the chemical rays in starting the 
regeneration of bone tissue and healing the fracture promptly. 

From the cancellous and compact tissue small islands of bone pro- 
ject and the proliferation takes place from the cells of the lamellae 
into the fibrils between the fragments. This is pure bone tissue from 
the start, and a plug forms, which fills the medullary portion of the 
bone ends and unites them firmly. This is called the definitive callus, 
which gives a stable and definite union between the fragments. As 
the provisional callus calcifies and becomes bony, it shrinks until its 
size approximates that of the normal bone before fracture. The size 

1 Ann. Surg., Iv, 781. 

2 Salvetti. Deutsch. Ztschr. f. Chir., cxxviii, 130. 

3 Med. klin., Berlin, xi. No. 8. 



REGEXERATION OF BOXE 25 

is partly governed by the degree of reduction to former alignment. 
If there is no angular or other disi)laeement, the provisional callus 
is small and after many months might show no gross evidence of 
fracture, so closely does it return to the normal contour of the bone. 
In lateral displacement with oblique lines of deposition the weak 
side which bears the stress of weight or muscular action fills in firmly 
and fully, provided the periosteal bridge is present. After function 
returns this callus becomes permanent, and as the limb is used, there 
is a natural attempt to restore a good axial line of strength by absorp- 
tion of the bone on the convex side of the line of greatest functional 
use and a building up of bone on the concave side. This is particularly 
noticeable in children, who may thus overcome an angular deformity 
to an extent which after a few years' time prohibits recognition by 
comparison with the uninjured limb. 

Joint fractures, or those in sites of muscle origin and insertion, 
where tendon sheaths or fascial layers blend with the periosteum, may 
cause the formation of callus and permanent bone in the structures 
mentioned. This is caused by traumatic separation of the periosteum 
with liberation of cells from the periosseous layer or bone into sur- 
roundings favorable for regeneration, or an imbedding of periosteal 
shreds, membrane-like, about the region of hemorrhage. These areas 
pass through a cartilaginous stage like ordinary callus, and may 
later become separated from the neighboring bone and lead to irri- 
tative symptoms.^ Traumatic myositis of similar character is seen 
in cavalrymen, shoemakers, and others whose occupations furnish 
the constant irritation of one muscle or part of the body. Some of 
these cases do not represent real bone formation, but are a calcification 
of infections or hemorrhagic processes. 

Permanent repair process in bone is slow. Can the formation of 
a satisfactory definitive callus be hurried by early use or motion of 
the part? ^Massage, without gross motions which disturb the healing 
fragment ends, is of use in promoting better blood supply in the sur- 
rounding tissues and possibly aids in hurrying the return of function 
by a vicarious action of exercise. It may also favor an early absorp- 
tion of the provisional callus. 

If early motion is violent enough to break up the capillary network 
on which the true bone proliferation proceeds, it will delay the pro- 
cess of repair. If more hemorrhage is caused, greater time will be 
needed to absorb the extravasated blood and the superficial bone 
layer which becomes necrotic in consequence of its loss of blood supply. 
As a rule, it is wise to maintain a relative immobilization for a long 
period in bones which will be subject to great stress and strain of 
body weight to avoid both these conditions and the clinical bending 
of soft callus and subsequent loss of function. Around joints where 
small exuberances of callus may cause great interference with motion, 
a long rest is indicated. This does not imply a tight, heavy cast of 

1 Fay, Sure:., Gynec. and Obst., August, 1914; FrariKonhoim, Arc-li. f. kliii. ("liir., 
Uxx. 44.5; Doutsfh. rrifd. Wr-hnsfhr., xxxix, 407; Ortli, Bfil. kliii. Wrlnisclir., xliii, 4:^0. 



20 BONE 

])laster, but it does mean quiet, rest without rough manipulation or 
liaiidHng, until continuity is firmly established. Helpful massage 
can be given without endangering })rompt union. 

Sluggish union, or delayed union from uids:nown causes, is often 
stinudated by use and mechanical irritation of the fragment ends. 
This is provided through the application of strains in the normal 
axis and direction of the limb, especially of the leg, by the operator 
encasing it in plaster or supporting it in normal position by means 
of a splint and then encouraging the patient to bear a little weight on 
it. This gives a slight irritation at the bone ends which stimulates 
regeneration. Various other means are used to attain the same result. 
(See Pathology and Ununited Fracture.) 

What is the effect of implantation of foreign bodies like nails, screws, 
or steel plates on callus formation and bone union? This point is 
dealt with in the chapter on Operative Treatment, but some general 
observations may be made. 'Nails and screws have little or no effect 
on callus formation and union. Their presence in long bones occupies 
such a small area that their action, if untoward, is limited and of no 
value. Clinically I have never seen any untoward effect from them, 
assuming of course that there is asepsis and immobilization and a 
fair reposition of fragments. Plates fixed with screws have given 
various results in different hands. Some surgeons believe there is 
not the slightest doubt that such plates cause a delay in union and 
frequently lead to non-union. If w^e consider that the plate occupies 
but a small area of the total bone circumference, it does not seem pos- 
sible that it can interfere much with blood supply and bone growth. 
The various experiments to determine the effects of plates or internal 
splints of foreign material have led to different conclusions. Macewen 
in his silver-ring experiment believed that he obtained bony growth 
beneath the ring with periosteum stripped off, and for that reason 
assigns the role of limiting membrane to the periosteum. Mayer and 
Wilmer, who repeated Macewen' s experiments, using steel or glass 
caps, obtained no growth beneath them, and Hey-Grooves, who 
attempted to determine whether rapidity and firmness of bone repair 
were better promoted by intramedullary pegs or external plates and 
screws, failed to comply with technique and after treatment used on 
human beings. His results showed that without additional external 
fixation, the screw holes of attached plates became loose and sepsis 
was likely to follow. This would naturally follow when the plate was 
made to take up the strain of the whole bone shaft in use permitted 
before there was any bone union. The stress on the screws caused 
pressure and absorption of the bone in which they were embedded. 
By using long plates held firmly by cotter pins which pierced the 
bones and were bound down tightly, he obtained better results, with 
little external callus, and examination of specimens showed an aseptic 
necrosis of the bone up to the level of the first pin on either side. He 
thought that the bent pins kept the periosteal blood supply away from 
the broken ends. It is my observation that best results follow plates 



BONE TRANSPLANTATION— FATE OF TRANSPLANTS 27 

applied firmly outside of the periosteum, to liold fragmeuts in place 
until strong union has followed. If they are not so j)laeed they may 
hinder repair through allowing movement and mechanical irritation, 
hone absorption, fluid collection, with sinus formation and sei)sis fol- 
lowing. The muscular tension acts on healing tissue, it is not taken 
up by the inefficient fixation splint, and union is delayed. Bone does 
not act like wood ; being a living tissue subject to biological reaction 
it will not maintain for a long time any screw thread whidi has been 
inserted into its tissue, provided the surface of this thread is subjected 
to continuous strain. The thread cuts its way through until tension 
is relieved. Healing takes place only when there is a condition of 
equilibrium, and the conclusion must follow that ne3:t to asepsis, 
mechanical efficiency of fixation is of greatest importance. 

Outside metal collars of any metal give good fixation when placed 
between bone and periosteum, but the collar interferes with external 
callus, and although a firm internal callus develops, the method has 
no practical value. If applied loosely enough to permit bone growth 
beneath, it would also allow movement and inhibit union. Hey- 
Grooves says: ''When the periosteum is excluded, union by callus 
still occurs, but the field of repair, being shut off from the vascular 
supply of the periosteum, produces its callus slowly and in small 
quantities." In comminuted fractures all fragments should be pre- 
served, as they become centres of bone proliferation. Consequently, 
if open operation is done, the operator should avoid interfering with 
the blood supply of these small fragments by manipulation. Near 
joints a difterent problem arises: no great amount of callus and no 
rigidity is desired; hence it is advisable to remove small fragments 
which cannot be very accurately replaced, and to avoid motion for a 
longer time. This procedure lessens mechanical irritation and exces- 
sive or function-restricting callus. 

BONE TRANSPLANTATION— FATE OF TRANSPLANTS. 

In reality this work is interested in bone transplantation only 
insofar as it concerns the treatment of recent or ununited fractures 
by inlay grafts or intramedullary splints. There are several different 
views held by experimenters and clinicians, and as the controversy 
still rages and no final decision has been reached at this time, it is 
evident that it lies without the scope of this work to make authori- 
tative decision. In a previous statement it has been said that bone 
regenerates from the osteoblasts in the subperiosteal layer, from tlie 
endosteum and the cancellous tissue. When bone is removed and 
reimplanted into a bony bed of the same animal, when there is autog- 
enous grafting, with asepsis, a bone union results. What is the fate 
of the transplanted bone? Is it absorbed completely or partly; does 
it become necrotic and offer its structure as a framework for regen- 
erating bone entering the area, or does it continue to live and enter 
into the final bone union as one of the essential elements? A'arious 



28 BONE 

authorities, with ideas fixed by ehnieal or experimental coiielusion, or 
a eoinbinatioii of both, haA'e (hfl'erent ideas. For the purpose of ehnieal 
results and a sueeessful bony union in fresh or ununited fractures, it 
seems best to use transplants with periosteum attached. Macewen 
and INIcWilliams hold that the transplant lives in part at least. 
Murphy believes that the transplant dies and offers a framework 
to regenerating bone which creeps along it, Earth's original idea. 
Clinically bone pegs and transplants do disappear after a time, and 
Mayer and Welmer hold that this fact refutes Macewen's idea. 

Probably Lexer's statement^ that the function of the graft lies in 
the fact that it replaces missing tissue and enables the body to build 
up new bone is satisfactory from a clinical standpoint. Autoplasty 
is the method of choice; heteroplasty of bone boiled or in other ways 
sterilized has been done successfully, but it undoubtedly takes much 
longer to secure a bony union, the foreign body being absorbed as the 
new bone is laid down (PetroflF). Presumably the osteoblastic cells 
of the endosteum and periosteum of transplants retain their vitality 
because they are exposed to the serum of the new bed in which they 
are placed. Most of the cells deeper in must undergo necrosis, because 
they are deprived of nourishment. Under the necessary condition of 
asepsis and blood supply these two parts of the bone which retain 
life proliferate and cause a cementing of the graft to its new home. 
Some of these cells also grow into the Haversian canals of the deeper 
necrotic graft, absorb it, and lay down new bone. Clinically most 
operators use bone grafts with periosteum — it is the wisest course. 
If it is removed, experimental work seems to prove that the cementing 
callus and the osteogenetic substitution of the graft are very slow. 
The osteoblastic cells of the periosteum are lacking in part, and regen- 
eration comes from the endosteum and cancellous bone. There is 
also probably an ingrowth of the transplant by the generating cells 
of its new bed, when it is itself lacking in osteogenetic material. The 
endosteum and periosteum may be destroyed by infection or lack of 
nutrition, but most of the substitution seems to come from its own 
cells. 

REFERENCES. 

Davis and Hunnicutt. Bull. Johns Hopkins Hosp., xxvi, No. 289. 

Gallie and Robertson. Canad. Med. Assn. Jour., iv, 33, 

Lexer. Loc. cit. 

Hosmer. Northwest. Med., 1913, v, 329. 

Axhausen. Arch. f. klin. Chir., 1908, Band Ixxx, viii; Deutseh. Ztschr. f. Chir., 1907, 
Band xci; Arch. f. klin. Chir., 1911, Band xciv. 

Barth. Zieprler's Beitr. z. pathol. Anatom., 1896, Band xvii; Arch. f. klin. Chir., 1893, 
xlvi, 409. 

Phemister. Surg., Gynec. and Obst., xviii. No. 4; ibid., xix. No. 3. 

Murphy. Jour. Am. Med. Assn., April 7, 1912; Surg., Gynec. and Obst., xvi, 493. 

TurnbuU. Arch. Patholog. Inst, of London Hosp., 1908, ii. 

Mayer and Wehner. Loc cit., and Aich. f. klin. Chir., 1914, ciii, 732, 

Gallie. Am. Jour. Orthop. Surg., September, 1914, xii, No, 2, 

Putti. Arch, di ortopedia, anno xxx, Fas. ii, 1913; Soc. Med. Chir. de Bologna, 2 
Mai, 1913. 

1 Ann. Surg., Ix, 166. 



BONE REPAIR IN OPEN FRACTURE 29 

Bond. Brit. Jour. Surg., April, 1914. 

Albee. Am. Jour. Surg., 1914, xxvii, 20; ibid., March, 1915. 
Le\\-is. Surg., Gynec. and Obst., May, 1914, p. 572. 
Oechsner. Surg., Gynec. and Obst., 1914, xix, No. 4. 
Cohn and Mann. Southern Med. Jour., 1914, vii, 214. 
Morrison. Brit. Jour. Surg., No. 3, i, 376. 
Macewen. Ann. Surg., 1909, No, 6, 1, 959. 
Ganglophe and Bertein. Lyon Chir., xi, No. 6. 

McWilHams. Jour. Am. Med. Assn., 1914, Ixii, 346; Surg., Gynec. and Obst., Feb- 
ruary-, 1914. p. 159; Ann. Surg., April, 1914. 

BONE REPAIR IN OPEN FRACTURE. 

The process of repair and healing in open fracture may not vary 
from that of simple fracture. It is a clinical delight to obtain an open 
fracture with a small external opening which heals as quickly and 
happily as if it were a closed affair. This result is largely caused by 
the type of fracture, the open character being caused by force within 
the limb, and the factors which govern the changes in repair of open 
fracture. 

The two factors are, first, the greater local violence and destruction 
of tissue, and second, infection. ^Nlost open fractures have been 
subject to greater direct violence with crushing and mangling of the 
soft parts. Muscles, fascia, periosteum, and bone have been severely 
injured and their blood supply interfered with beyond the usual 
damage of closed fracture. Even with infection and suppuration 
absent, it is easily understood that repair and ultimate bony union 
will be longer in appearance if conditions of open fracture are 
present. When the fracture is opened from within, this violence is 
not commonly present, and sepsis is not so frequent. It is also true 
that a small hole through skin and soft parts acts as a drain, and the 
early blood extravasation, instead of demanding absorption within 
the tissues, is poured out into dressings, and the bone repair follows 
more quickly. Tissue reaction, absorption of traumatized soft and 
bony parts, reestablishment of circulation, and the subsequent bone 
regeneration will demand a longer period of time than in cases of 
simpler closed fracture. 

Infection, the second factor of importance, also delays the process 
and modifies it. I believe that trauma and interrupted blood supply 
have much more to do with a delayed callus formation by the perios- 
teum than infection has. This opinion is based on experience with 
open fractures and the resection of bone shafts in osteomyelitis of 
different degrees. In the presence of infected bone the periosteum 
will go on forming new bone until an infected shaft will approximate 
twice its normal size, and if this necrotic bone is peeled out of its cover- 
ing the perio.steum will be found relatively healthy and active. Its 
vigorous blood supply accounts for this condition. Another striking 
example of })one liealing and regeneration in the face of sepsis is found 
in the ril)s after resection with (h'aiiiage for empyema of the chest. 
When bone becomes infected, its lym])hati('s plugged and its blood 
supply interfered with, necrosis surely follows, but j)eriosteum is not 



30 BONE 

affected so extensively. Consequently repair is slower in infected 
open fractures, not so much because the periosteum is destroyed by 
the infection, as because it has suffered greater destruction from loss 
of nutritive supply. Infection on top of this may cause the bone 
covering to fall an easy prey in company with the bone itself, but, as 
a rule, the periosteum retains its vigor and life more tenaciously than 
the bone, and the longer time required for union in infected fracture 
must be accounted for by the bone reaction. 

Small fragments live and become the centre of new bone growth, 
if their blood supply is sufficient and infection does not overcome 
them. It is better to leave them lying in the wound, although they 
may appear unprotected. Bony granulations gradually cover the 
site of fracture, and fragments deprived of vascular connection, 
although really foreign bodies, are well tolerated by bone, very much 
as implanted autogenous bone is. If the field is sterile, no subsequent 
trouble is looked for; if infection appears, these small pieces will 
probably be cast out or need to be removed. 

Bone extruded through an opening in the flesh and deprived of 
usual surroundings may necrose, and a line of demarcation may mark 
the level of living and dead tissue, as in other structures of the body. 
It is also a fact that the thin external surface or shell of this bone 
may necrose alone and leave viable tissue beneath. Deeply planted 
infection in osseous tissue thrives largely because of the physical 
structure of the bone and its limited blood supply. There is not much 
chance for the phenomena of protective inflammation to build up 
quickly a resisting wall of leukocytic infiltration. The rigidity and 
hard structure forbid this. Reaction to deep infection is slow; necrosis 
of the areas in which a circulatory stasis develops is the outcome. 
Consequently infection introduced by screws of Lane plates or other 
foreign bodies penetrating the compact layer, finds little resistance 
and causes a prolonged suppuration and necrosis. When a bone shaft 
is extruded in open fracture and its covering is retained, infection is 
warded off by the periosteum, and this bone may be open to the air 
for a long period of time and retain vitality and show no infection 
which leads to necrosis and suppuration. It is less liable to be sub- 
ject to a suppurative process than bared bone lying in soft tissues, 
because it is dried and not constantly surrounded by the tissue fluid 
and serum which do not drain away completely. I saw an example 
of this type of open fracture recently with Dr. Kelly at Mercy Hos- 
pital. A woman had received a severe skull fracture and an open 
fracture of the left arm just above the elbow. She was in very bad 
condition, and although a decompression of the skull was performed, 
the case was classed as almost hopeless. To avoid additional shock, 
the arm, with several inches of humerus protruding through the skin, 
was dressed and no effort at reduction was made. After being in a 
critical condition for days, she eventually made a recovery. The 
humerus has received no attention looking toward reduction. Three 
months later when I saw her, the soft parts above the elbow had 



BOXE REPAIR IX OPEX FRACTURE 31 

healed, and there were four inches of the shaft of the humerus pro- 
truding, covered with dirty yellow and red granulations, but not 
suppurating. It was quite dry. Operation was performed, and the 
lower fragment, which consisted of the humeral condyles, was laid 
bare and freshened. The arm had contracted somewhat on account 
of lack of bone support, but instead of cutting ofT the protruding por- 
tion of the shaft of the humerus, the granulating fungus-like covering 
was peeled off, and bone which had blood supply and appeared viable 
was found beneath. By manipulation and nicking of the muscles, 
a reduction was accomplished, the freshened bone ends were fastened 
\dth silver wire, and a recovery without suppuration followed. This 
bone had been protected by periosteum and the dry dressings, and no 
infection had occurred deep in its tissue. 

Callus repair in open fractures generally takes longer than in closed 
fracture. There has been more injured tissue to absorb, the bone 
reaction has been more vigorous, and the necessity of dressings or 
drains and manipulation has caused more motion at the site of fracture. 
Irregularities of the callus and adherence of the soft parts to it are 
the usual sequels. If infection is a part of the recovery, the tender- 
ness of osteomyelitis is added, and after recovery the fracture is 
tender, enlarged, and troublesome. Deeply buried fragments or 
infection may prolong irritation for many months. Absorption and 
final changes long after union leave an irregular callus, some areas 
very hard and eburnated, others pitted. Bony trabeculse may extend 
along fascial planes or tendon insertions, as mentioned previously. 

Fractures which involve the ends of the long bones, where the 
compact layer is thin and cancellous tissue composes the greatest bulk 
of the surface, heal rapidly without much preliminary absorption. 
Regeneration is derived from the spongy bone, the periosteum furnish- 
ing less callus and usually suffering less injur}^ or stripping, because 
it is held by attachment of ligaments and tendons. In malleolar 
fractures at the ankle it is an ordinary finding on the performance of 
open operation for nailing, that the bone tip is broken completely 
off and the ligaments and periosteum are torn off quite exactly at 
the line of fracture. The periosteum does not tend to strip. up. These 
fractures are replaced exactly and held in position by nails. After 
six weeks, when splints are removed, the malleoli are in normal posi- 
tion, the patient can at once move the ankle quite freely, but in spite 
of the careful reposition the ankle seems swollen and thick. This is 
not all callus, but is parth', I believe, the infiltration in the soft parts 
and ligaments which has not subsided. It in no way interferes with 
motion and function. I have never yet had an opportunity to dissect 
an ankle after nailing and healing, nor have I ever taken out but one 
nail, so that definite pathological knowledge of this swelling is not 
yx)ssessed by me. 

When the line of fracture enters the joint surface, the articular 
opening heals by granulations from the synovial membrane and the 
cancellous bone, as there is no periosteum there. Rarely the callus 



32 BONE 

from the spongy bone is exuberant and extends out into the joint. 
As previously stated the joint cartilage does not regenerate much, 
and the fracture is fixed by the extra-articular callus arising from the 
periosteum. The line of separation often follows the epiphyseal line 
or cartilage when they are still present. This point is discussed under 
Wrist Fractures, many of which, in children, are of this character. 
If they are replaced, union and growth seem to be normal in every 
respect. There are a few cases on record in which the cartilaginous 
area has been overcome by the osseous reaction, becoming calcified, 
and growth has ceased. 

Excessive callus usually is an unwelcome complication in any 
fracture. Near joints this condition always interferes with motion 
and function, and it should be guarded against as much as lies in the 
power of the surgeon by his obtaining accurate apposition of the 
fragments and avoiding early movement, which may cause bony 
proliferation. A very small amount of callus which fills a normal 
depression in bone, like the olecranon fossa, or which protrudes but 
slightly in the way of normal joint action, often causes much disability. 
Likewise when two broken bones lie close together callus may unite 
all four fractured ends or spread out between them via the interosseous 
ligament and stripped periosteum, leading to great restriction of 
motion. (See Fracture of Forearm Bones.) As a rule, however, the 
calluses, even when exuberant and approaching each other, form a 
smooth surface when in contact which permits movement of rotation. 
Clinically this is of little importance in the leg, ribs, or any other part 
of the body except the forearm. 

The opposite of excessive callus is observed in those cases of non- 
union in which bone rarefication has taken place and granulations 
have proceeded, but calcification and osseous formation have not 
followed. Use and motion may cause formation of a false joint at 
the site. (See Pathology.) The condition is found in the shafts of 
long bones, in the neck of the femur and in the patella, olecranon, 
head of the radius or humeral condyle, or other portions broken off 
near an articulation. The underlying cause is lack of blood supply 
to both bone and periosteum, or destruction of periosteum and its 
generating osteoblasts. 



COURSE OF FRACTURE. 

The clinical course varies with the patient's general condition, age, 
the complications which arise, and the character of the reposition or 
other treatment. There is a change in behavior according to general 
constitutional diseases or conditions which seem to depend, as sug- 
gested, on the calcium equilibrium. Lane believes that alcoholism 
is one of the greatest disturbing factors of ordinary bone repair. 
Syphilis, tuberculosis, rickets, and other constitutional diseases like 
diabetes, acromegaly, or constitutional conditions of obscure origin 



COURSE OF FRACTURE 33 

like arteriosclerosis, myocarditis, or even varicose veins, have an 
influence as described in the chapter on Pathology. 

The course may be divided into local and general eft'ects. After 
the first few hours of nervous upset, or local pain, an individual who 
has suftered fracture is usually comfortable, unless he is disturbed 
by tight bandages and splints or useless manipulation. These lead to 
muscle spasm and twitchings and aching discomfort. The injured 
member is shortened and enlarged on account of edema and bone 
displacement. If the limb and part are placed in a comfortable posi- 
tion the first reaction slowly subsides; swelling and edema disappear 
after reaching a maximum on the third to fifth day. Ecchymoses 
and blebs become noticeable later and may last for weeks. The 
greatest discomfort in the normal course is not pain but the irksome 
confinement, the wearing of splints, disability, and change of daily 
habits. Fat embolism is manifested within twenty-four hours, pul- 
monary embolism from a dislodged clot usually occurs after several 
days. Pneumonia caused by the trauma, exposure, or recumbent 
position comes on within a few days, as do also the sequelae of alco- 
holism. Delirium tremens may take onset within twenty-four hours 
after fracture, if the patient is a pronounced alcoholic and the supply 
of alcohol is withheld. It also comes on late in less pronounced 
habitues — or follows an anesthesia administered for reduction and 
dressing. Very rarely after an early alcoholic delirium and recovery 
the patient will relapse into a second attack within a week. The aged 
frequently develop an asthenia or hypostatic pulmonary congestion, 
and death from exhaustion ensues. 

A fever is often found clinically, caused by an aseptic absorption 
of the extravasated material at the fracture site. From this cause 
alone the temperature rarely goes above 100° F. The kidneys may 
be influenced by this absorption, and the urine may show albumin 
and casts for a day or two. Fat distributed by absorption and fat 
embolism or lipemia is also excreted from the kidneys. An increase 
in the white blood cells is also a constant clinical finding, afl'ecting the 
polymorphonuclear cells. The eosinophiles are first decreased in 
proportion and later increase in healthful reaction. The blood changes 
all become normal after two weeks. 

Eight or ten days after injury, if rest has been aft'orded to the limb 
and ice has been applied, the swelling and edema disappear, and the 
ecchymoses with tints from black to light yellow are prominent. The 
external callus can be felt through the superficial tissues as an oval, 
firm mass. This becomes harder and at first may increase slightly in 
size; later it shrinks, the false point of motion at the seat of fracture 
is no longer demonstrable, and union exists. The diminution in size 
of the callus takes a varying time, depending on the individual and 
the type oi fracture. Some enlargement is often permanent and can 
be felt after many years. This repair and absorption of callus is more 
vigorous in eliildren and in cases where there arc no (•()inj)lir;iti()iis. 
Each bone has its own period of repair, which will be indicated in sub- 
3 



34 BONE 

sequent chapters; Long bones require a longer time to heal than 
small bones. Shaft fractures of long bones with a thick compacta 
require a longer time than fractures through the cancellous portions 
and poor alignment, comminutions, and other unusual pathology 
requires greater time for union. A phalanx may unite in two weeks; 
the neck of the femur might not present solid union after six months 
or a year. 

Many fractures which are well reduced and splinted are mishandled 
in after treatment because sufficient rest, time, and splinting are not 
permitted to allow the callus to become calcified and fit for weight 
bearing. These points are discussed under the different bones, espe- 
cially in femoral, forearm, and ankle fractures, in which too early use 
may lead to a deformity as bad and as disabling as the original dis- 
placement. The mere fact that callus has formed between bone ends 
does not terminate the care of the fracture, any more than the healing 
of a laparotomy wound and removal of the stitches indicate that the 
patient is again restored to normal. The bone wound or scar will 
stretch much more than a union in soft parts because when function 
is started it is subject to greater stress and strain. The limb involved 
must also undergo some nutritional changes on account of rest and 
muscle inactivity. After splints and casts are removed permanently, 
even when massage has been used in the course of repair, there is 
considerable swelling and edema from circulatory and lymphatic 
changes. Use soon overcomes most of these conditions, but the dis- 
ability after fracture, the stiffness and soreness in neighboring joints, 
and the little aches and pains are sources of discomfort in many 
patients. Perhaps this is particularly so in a neurasthenic class. 
Artisans and laborers generally forget the trouble in the struggle for 
existence. 



CHAPTER II. 

ETIOLOGY AND :MECHAXISM OF FRACTURE. 

The causes of fracture are (1) predisposing causes and (2) exciting 
or immediate causes. The predisposing causes are: 
(a) Functional or physiological. 
(6) External influences, occupation, season and exposure. 

(c) Pathological conditions. 

(d) Intra -uterine and obstetrical. 

Fracture may be defined as a solution of the continuity of bone. 
Predisposing causes for this solution are found in: 

(a) Functional or Physiological Causes. — These lie in the fact that 
bones act as a protection to body viscera and soft parts, as the 
skull protects the brain and the ribs, the chest, and that as the rigid 
framework of the body, the bones must finally take up the stresses 
and strain, transmitted by the muscles and ligaments, which come in 
ordinary exposure and work of life. As we have seen in the chapter 
on Bone, the structure is adapted to these necessities, but when a 
limit of elasticity is passed, the bone continuity suffers. Physiological 
changes incident to constitutional disturbances, or physiological 
periods of life, also predispose to fracture. The calcium equilibrium 
undoubtedly is a factor of great importance. The atrophy of the 
trabecul^e of the cancellous tissue, the increased calcification of the 
compact layer, and the increase of fatty medullary substance in the 
aged, are also factors of interest. These may reach such a degree 
that they border on the pathological. The bones of certain individuals 
who are otherwise normal seem predisposed to fracture by an hereditary 
influence or some personal idiosyncracy. ^Members of families for 
several generations may show a tendency to easy and frequent fracture. 
Gurlt's Hcuidhuch cites one family as disposed through four generations. 
Individual tendency in this direction is often met with, and there are 
-scattering reports in the literature — the number of breaks in one indi- 
vidual amounting sometimes to more than a score. I have recently 
cared for a man who gives the following history of fracture in the last 
thirty-six years. He first sustained a fracture of both bones of the leg. 
Two months later he fell on some ice and fractured the femur, and ten 
years later he sustained a bimalleolar fracture, all in the same leg. 
After an interval of several years he had a Colles fracture of the left 
arm and finally had a fracture of the anatomical neck of the left 
humerus. The Pioentgen ])icture k'aves no doubt that there is some 
calcium deficiency in his bones, but there is no ^•ariati()u in size or 
any other evidence of pathology in the skeleton to account for his 
peculiar liability. 



36 ETIOLOGY AND MECHANISM OF FRACTURE 

(b) External Influences. — Other predisposing causes arise from 
outside influences incident to occupation, sex, age, season, and 
exposures of life. Occupation and sex are closely intermingled, 
because males as a rule perform the harder labors and are occupied 
in more dangerous work. In a consecutive series of 10,702 fractures 
studied at the Cook County Hospital I found that there were 7954 
closed fractures and 399 open fractures in males and 1154 closed and 
27 open in females. The remainder were in children. An investigation 
of occupation in this same series shows that 2662 were laborers, 
who performed relatively rough work of all classes which furnished 
exposure to trauma. Teamsters came next in the numerical list, 
furnishing 737 instances of fracture. Naturally it is impossible to 
decide which occupation is the more hazardous — ^figures could not tell 
us that unless an exact number of men in the different trades were 
working in one vicinity under the same conditions, and observations 
made on them for a period of years. Painters pursue a hazardous 
occupation, and though it is impossible to state the relative number 
of them at work in the community contributing to this hospital, 
I have selected them as a means of comparison. Of 10,702 fractures, 
277 were in painters. Carpenters furnished about | as many cases 
as painters, firemen | as many, mechanics or foundry men about | 
as many, and trainmen about J as many. In the female sex housewives 
furnished 647 cases, cooks and domestics about i as many, and wait- 
resses a very small proportion. Seasonal variation is not so important 
as former writers thought. The modern city with surface trans- 
portation, a large amount of summer building and extension, and a 
restriction of these activities in the winter, counterbalances any great 
increase in fractures caused by falls on ice or weather conditions or 
the doubtful influence of muscles stiffened by cold and exposure. 

My analysis of eight years' admissions to the hospital on account 
of fracture showed that there were 2688 in the summer, 2675 in the 
spring, 2624 in the winter and 2560 in the autumn. 

(c) Pathological Fractures. — Pathological conditions which represent 
diseases of the bones themselves, or metastases and extensions of 
disease from other parts of the body, include the third class of elements 
predisposing to solution of continuity. These injuries have also 
been called spontaneous fractures, because they seemed to be caused 
without any violence, the fracture occurring in an ordinary act like 
walking, stepping, or swinging an arm. The bone is weakened by the 
pathological condition until it is no longer able to bear even mild 
stresses, and slight exertion or movement is all that is needed to pro- 
duce fracture. Pain is often absent. The patient walking feels a leg or 
thigh give way and falls down helpless, or in turning or being moved 
in bed feels something snap and finds a limb useless. 

In the chapter on Bone attention is directed to the importance 
of the constant growth and changes in the bone after it is laid down 
and to its metabolism which corresponds to that of other tissues. 
The calcium equilibrium is disturbed in many conditions, such as 



PATHOLOGICAL FRACTURES 37 

osteoporosis, chronic infection of syphilitic or coccic origin, osteo- 
mahicia, rickets, dwarfism, etc., the calcinm salts either being diverted 
to other tissues or perverted into bony deformities. A pregnant 
woman draws on her store of calcium to supply the fetal bones, and if 
a balance is not restored after the child's birth a condition of osteo- 
malacia may result. Tumors, primary or metastatic in bone, fractures, 
arteriosclerosis, a lessened bone-building power of old age, and other 
conditions cause a similar calcium depreciation. iNIcCrudden in his 
work on infantilism at the Rockefeller Institute^ made a study of the 
metabolism of proteins, carbohydrates, fats and inorganic salts. He 
believes that clinical cases of defective growth may be divided into 
two classes: one with tender and undeveloped bones and disturbance 
of calcium metabolism, the other, without calcium deficiency and w ith 
normally thick resisting bones. 

As nearly as can be decided from the literature, fragilitas ossium,^ 
osteogenesis imperfecta, and idiopathic osteopsathyrosis,^ are all the 
same condition. There is a congenital lack of power to form bone, the 
laminae are imperfectly calcified or are lacking altogether, there is an 
aplasia of both compacta and spongy tissue, so that fracture easily 
occurs. This is always in the diaphysis, according to Maier. 
Achondroplasia usually affects the cartilage and not the bone, osteo- 
malacia concerns calcium changes in grown bones, and rickets concerns 
the whole bone, including the epiphyses. Repeated fractures of 
infant bones are really found in osteogenesis imperfecta alone, and 
Bookman^ and Bamberg and Huldschinsky^ agree that there is a 
negative calcium balance. Phosphorized cod-liver oil probably 
increases the calcium retention. Many fractures arising from this 
condition occur before birth, and many fetuses are born dead. The 
bone fragility is noticed from the ninth month to the second year, 
when the child is learning to walk, or from the sixth to the fourteenth 
year upon physical exertion. Shortening and deformity in the bones 
are caused by the fracture displacement. The fractures of early 
childhood are most often transverse and heal with much callus, while 
those of the late form are also oblique and tend to heal very slowly 
with poor callus formation. Blue color in the sclerse is considered a 
pathognomonic sign.*^ 

Other interesting isolated cases are recorded by Remy^ and Plisson.*^ 
The former's patient was twenty-six months old. He sustained in all 
six fractures within a period of a year w^hile w^alking across the floor. 
These were all rapidly and completely repaired. Plisson's case had 

1 Deutsch. Arch. f. klin. Med., Band ex, Heft 1 u. 2, p. 90. 

2 Ostheimer, Jour. Am. Med. Assn., Ixiii, No. 23, p. 1997. 

' Frangenheim, Ergeb. d. Chir. u. Orthop., iv, 134; Axhausen, Deutsch. Ztschr. f. 
Chir., xcii, 42; Lobstein, Traite d'anatomie pathologique, 1833, ii, 204. 

* Am. .Jour, of Dis. of Children, 1914, vii, No. 6, p. 436. 
5 Jahrb. f. Kinderh., 1913, IxxAnii, 1214. 

* Burrows, Brit. Med. Jour., 1911, ii, 16; Cockayne, Ophthalmoscope, 1914, xii, 271; 
Conton, Bost. Med. and Surg. Jour., 1913, clxix, 16. 

7 The Medical Council, xix. No. 1, p. 15. ** riii,ique, 1913, p. 132. 



38 ETIOLOGY AND MECHANISM OF FRACTURE 

eig'hteeii spontaneous fractures in nineteen years and was then put 
under treatment l)y adrenalin, since when no fractures liave occurred. 

Kickets with softening and bending of the hone also furnishes 
a pathological basis for fracture, largely by a change in the calcium 
content, which causes loss of firmness and rigidity. Old dislocations, 
particularly those of the shoulder, may lead to fracture of the bone 
from slight trauma or efforts at reduction. The bone probably under- 
goes an atrophy of disuse, and less force is needed to cause fractures 
than under normal circumstances. The atrophy is really a change in 
calcium content, and though more force is applied than the operator 
intends there is also a weakening of the bone. I have fractured the 
humerus in a dislocation of three months' standing while attempting 
reduction and talking of this very point, the necessity of guarding 
the amount of force expended. 

The nervous system also has on bone an influence which predisposes 
to fracture. Neurotrophic influences in insanities, in paralyses and 
particularly in tabes must be considered. In the Cook County Hospital 
we have from 12 to 15 cases each year of pathological fracture or frac- 
ture-dislocation of the long bones in tabetics. These are usually near thq 
joints, they are accompanied by much bone change of a rarefying 
or hypertrophic character of typical Charcot joints, and they are 
also quite painless. Some patients present three to five fractures 
at the same time. Many of these heal, and a deformed but function- 
ating limb results. Rarely a fracture of this character is the first 
intimation of a parasyphilitic condition, well-developed tabes appear- 
ing in a few months or a year after a fracture from trivial cause. 

Syphilis itself rarely leads to pathological fracture. The bone 
changes are almost always hypertrophic in character, and shafts 
are greatly thickened. Tuberculosis sometimes, in an isolated area, 
leads to pathological fracture. Parker^ has reported a case due to 
tuberculosis in the lower end of the femur which healed promptly. 
Pathological fractures are also caused by multiple myelomata, or are 
found in cases of myelopathic albuminosuria, as described by Bence- 
Jones in 1847.^ 

Benign bone cysts, ostitis fibrosa or fibrocystic disease of bones, 
cause pathological fracture. Many cases are now on record in the 
literature, the spontaneous fracture, or one induced by operation, 
often curing the condition.^ Cysts caused by the echinococcus, 
cysticerci or actinomycosis or chronic osteomyelitis of bacterial 
origin'' may result in fracture. The diseased portion of the bone is 
not always the weakest, however, as shown in a case" with a spiral 
fracture of the normal part of the shaft of the humerus, with a bone 
cyst just above the site. 

1 Jour. Am. Med. Assn., September 19, 1914. 

2 Groves, Ann. Surg., Ivii, 163. 

» Lewis, South. Calif. Pract., April, 1910; Elmslie, Brit. Jour. Surg., ii, No. 5, p. 67; 
Stierlin, Deutsch. Ztschr. f. Chir., June, 1914; Low, Lancet, January 31, 1914. 
* Landois, Med. Klin., Berlin, 1914, x, 269. 



PATHOLOGICAL FRACTURES 



39 



Malignant disease, particularly sarcoma and carcinoma, is the most 
common cause of pathologic fracture. Pathologically it is known that 
certain carcinomata, especially of the breast, prostate, adrenals and 
kidneys, and malignant goitre, have a predilection to establish metas- 
tases in bone-marrow.^ The erosion and weakness in structure which 
they cause and which result in spontaneous fracture may be the 
first clinical evidence of the disease. There is no primary carcinoma of 
bone but primary sarcomata are common. Diffuse carcinomatosis 
of bone metastatic from other tissues with multiple fractures, is 
illustrated in Figs. 1 and 2. The humerus and femur are favorite 




Fig. 



1. — Extensive carcinomatous involvement of the bones. Right clavicle and humerus 
are the seats of pathological fracture. 



sites of involvement, and there are clinically few symptoms of pain or 
bone disease before the spontaneous rupture. Hawley^ quotes Limacher, 
who found metastases in bone from carcinoma of the breast in 7 cases, 
and I^nzinger, who found the bone metastases of carcinoma of the 
thyroid comprised 37 per cent, of cases. Almost invariably more than 
one bone is involved, a condition differing from some forms of sarcoma 
which have a solitary metastasis. The vertebrae, humerus, femur, 
ilium, ribs, sternum, skull and bones of the extremities are usual sites, 



1 von Recklinghausen, Festsch. z. Virchow 71, Geburtstag, Berlin, 1891, 

2 Ann. Surg., li, 636. 



40 



ETIOLOGY AND MECHANISM OF FRACTURE 



the metastatic invasion being of miliary type from the blood, affecting 
the long bones in the marrow of their expanded extremities and the 
vertebrje in their bodies. A slow restricted growth of the newly 
deposited tnmors resnlts, osteoporosis extending from within outward 
proceeds, and there is a compensatory periostitis which forms new 
bone. Compared to the number of these metastatic growths, the 
complicating spontaneous fractures are quite few. Weakness and 




Fig. 2. — Lower extremity of the preceding figure. Carcinomatous invasion of the bones, 
pathological fracture of the femur. 

pain or deep tenderness over the bones are symptoms, but tumors 
gross enough to attract attention are rare (Fig. 3). 

In the discussion of Rodman's paper on Cancer of the Breast read 
before the Clinical Congress of Surgeons at London, July 31, 1914, 
Handley^ brought out some interesting figures in support of the 
permeation theory of the spread of carcinoma via the lymphatics. 



Surg. Gynec. and Obst , 191:", p. 72. 



PATHOLOGICAL FRACTURES 



41 




Fig. 3. — Carcinomatous invasion of the femur with a comminuted fracture through an 
apparently healthy portion of the bone above. 

SPOXTAXEOUS FRACTURE IX 329 CASES OF MAMMARY CAXCER AT 
THE MIDDLESEX HOSPITAL. 1872 TO 1901. 



Bones lying wholly or par- 
tially within the area liable 
to .subcutaneous nodules. 



Bone. 

Sternum 

Ribs. . . . 

Clavicle . 

Spine 

Cranial bones . 

Scapula^ 

Femur . 

Os innominatum^ 

Humerus 



Bones lying Vjeyond the area 
liable to subcutaneous nod- 
ules. 



Radius . 
Ulna 
Tibia 
Fibula . 
Patella . . 
Bones of hand 
Bones of foot 



No. of 


Percentage 


cases. 


of total. 


30 


9.0 


28 


8.0 


5 


1.5 


12 


3.6 


9 


2.7 


1 


0.3 


14 


4.2 





0.0 


9 


2.7 





0.0 





0.0 


1 


0.3 





0.0 


1 


0.3 


1 


0.3 





0.0 



1 This bone, owing to its shape, is not much liable to spontaneous fracture, and rarely 
comes under observation at an autopsy. 

2 Knee ankylosed, femur aflfected in its whole length, with extension of growth to 
patella and head of tibia. 



42 



ETIOLOGY AND MECHANISM OF FRACTURE 



lie believes that breast carcinoma always spreads in a centrifugal 
manner tlirongli the lymphatics, the tract being obscured as the 
disease so permeates, and the whole condition can be likened to a 
gigantic ringworm. He offered the accompanying table in support of his 
study, and states that the arms below the elbow, and legs below the 
knees, are not the seats of metastatic deposits, although we would 
expect to find the evidence of embolism in the extremities if the 
distribution occurred via the blood stream. 

Sarcoma is often primary in bone and leads to spontaneous fracture. 
Some forms of sarcoma have a solitary metastasis in bones, especially 
the hypernephromas. Scudder^ reported a case of amputation of the 
arm for supposed sarcoma of the upper end of the humerus. Examina- 




FiG. 4. — Sarcoma of the femur and 
pathological fracture. 



Fig, 5. — Sarcoma of the humerus with false 
motion at the site of the tumor. 



tion proved this was a metastatic hypernephroma. Nephrectomy 
was urged but was refused, and after death five years later no other 
metastases were found in the body. Albrecht^ also says there are 
solitary metastases in hypernephroma. Primary bone sarcomata do 
not metastasize early and are difficult to differentiate from bone 
cysts. Removal of the part of the bone affected may be sufficient 
treatment. Whether sarcoma follows the trauma of fracture or not 
is a disputed point. I have removed the mandible for sarcoma of the 
jaw in a case which gave a history of fracture a year before at the same 
site, and the size of the tumor and lack of metastases did not seem to 



1 Ann. Surg., lii, 533. 

2 Arch. f. Win. Chir., Ixxvii, 1073. 



INTRA-UTERINE AND OBSTETRICAL FRACTURE 43 

indicate that the tumor had been in existence before the fracture. 
Coley has reported a case and Griffin^ reported sarcoma following the 
plating of a femur for fracture. INIurphy states that fracture is never 
followed by sarcoma — it is injuries of less degree which may cause the 
onset of malignancy. 

REFERENCES. 

Coley, Paper read before the 3rd Internat. Conf. of Cancer research, Brussels, August, 
1913; Weissenbruch, Brussels, 1914; Bloodgood, Ann. Surg., ii, 145; Mutel, Rcv.d'orthop., 
1913. V, 423; Burnham, Interst. Med. Jour., xx, 1021. 



(d) Intra-uterine and Obstetrical Fracture. — True intra-uterine 
fractures are not frequent, but there are over forty in the literature. 
Children may be born with healed, ununited, or fresh fracture, and the 
cause may be fetal disease, deformities, or non-development, and 
trauma received by the child in iitero or during birth. Intrapartum 
fractures occurring durmg childbirth often arise from instrumental 
or manual manipulations in artificial delivery. They may occur, 
however, during an otherwise natural birth, the contracting uterus 
forcing a limb against the mother's bony parts in such a manner that 
fracture results. These are all fractures caused by external violence. 

Other intra-uterine fractures are based on predisposing causes, 
such as chondrodystrophia, osteogenesis imperfecta, fetal rickets, or 
even congenital s}^hilis. The two last I do not consider real causes 
of fetal fracture, but they may have some influence in causing 
pathological epiphyseal separations. Instances of congenital deformities 
with fused or excess toes, absence of fibula, etc., cannot be considered 
under a heading of fracture. 

True intra-uterine fracture occurs in healthy individuals, and is 
caused by direct violence, as from blows or falls. Hamilton^ says 
that it may also be caused by muscular action, but that this is usually 
preceded by some constitutional cachexia. He cites a case of com- 
pound intra-uterine fracture. Bunton^ collected 32 cases of true 
fracture, most of which w^ere from falls or blows. Most of these injuries 
are sustained in the latter months of pregnancy. In Smith's collection^ 
of 44 cases, which includes all in the literature up to that time, only 
three were produced by penetrating objects, i. e., gunshot, sickle, 
and pitchfork. Falls were responsible for 22 cases, blows for 10, and 
pressure for 1. One case of fracture of the forearm bones was accom- 
panied by dislocation of the humerus. Thirty-eight cases in which 
the results for the mother and child were stated, showed two maternal 
and eight fetal deaths. The injury does not often interrupt pregnancy. 
In the collection mentioned 29 went on to term, 8 did not, and in 7 
cases the result was not stated. In 32 of the cases the fracture was 
single, in 5 multiple. In all, there were 12 fractures of the clavicle, 

1 Med. Record, 1913, p. 650. 2 Fract. and Dislocations, 6th ed., p. 31. 

'Tr. Am. Surg. Assn., 1884. ii, 425. 

* Surg., Gynec. and Obst., 1913, xvii, 355. 



44 ETIOLOGY AND MECHANISM OF FRACTURE 

1 1 of the skull, 1 1 of the \v^, 4 of the forearm, 4 of the humerus, 3 of 
the feuiur, aud 1 of the sea])ula.. 

The fact that these fractures do occur may assume medicolegal 
importance in cases where the mother has been subjected to some 
violence. In the discussion of Smith's paper. Dr. Ries,^ of Chicago, 
mentioned a case which had gone to court. A woman had fallen in a 
hospital elevator and the leg of her child was broken, an injury for 
which she sought damages from the hospital. Dr. Chas. Paddock 
had never seen a case but believed there were many which never found 
their way into the literature. 

EXCITING CAUSES OF FRACTURE. 

The exciting causes are: (1) external violence, divided into direct 
and indirect violence, and (2) muscular action. 

1 . Fracture by direct violence implies that the loss of bone continuity 
has occurred very near the site where the external violence is applied. 
The line of fracture may extend anywhere from this point, but that 
is its origin, unless there is a very weak point of the bone close at hand. 
Indirect violence, however, causes fracture at some distance from 
the point of application of force arising from compressional or torsional 
violence. This division of causes is an excellent clinical one, because 
it explains the great difference which exists between these two types. 
If sufficient force is applied to any part of the body to cause fracture 
of the bone beneath the soft parts, injury of these parts is always 
present. This may vary from extensive bruising with ecchymoses to 
laceration, open fracture, and gangrene of the tissues from excessive 
trauma. Occasionally the elasticity of the skin saves it from rupture, 
the soft parts and bone beneath are torn apart, and pressure necrosis 
of the skin may follow from the hematoma, although there are no 
visible marks of violence on it. Indirect violence results in a trans- 
mission of the force to a distant part of the bone or limb, so that the 
bone break is in another area. These fractures may also result in 
injuries of the soft parts; that is, the point where the violence is applied 
may be lacerated, or the parts about the site of bone separation may 
be injured and the skin punctured by sharp fragments forcing a way 
out. 

2. Fractures caused by pure muscular action are not numerous. 
It is necessary to confine to this class those bone injuries which are 
caused by the exertion of the muscles through their insertion and not 
with the help of any external violence or restraint. If a man catches 
his foot in the frog of a railroad track and in the violence of his efforts 
to extract it in the face of an approaching train, makes violent muscular 
exertion, and these exertions result in a twisting of his ankle and 
fracture, or he throws himself to one side with sufficient force to 
break his leg, the result is not considered fracture from muscular 

1 Surg., Gynec. and Obst., xvii, 391. 



GENERAL MECHANISM OF FRACTURE 45 

action. The same ruling applies to fractures received from falls or 
collisions where the body momentum has been caused by muscular 
action in running or walking. A fall on the hand while one is running 
may cause fracture of the wrist, arm, or clavicle. The injury is not 
caused by muscular action, but to transmitted stress down the rigid 
arm meeting with the sudden impact restraint of the ground. The 
best illustrations of fracture arising from true muscular action are in 
the patella and olecranon by direct pull of the muscles on the bone 
causing it to be torn apart. When muscles and ligaments are resisting 
force applied to a limb, or parts of the body, this type of fracture 
results. Illustrations are offered in fractures of the anterior superior 
iliac spine, of the fifth metatarsal bone, of the tubercle of the tibia, 
of the vertebn^^ and the greater tuberosity of the humerus, etc. Other 
cases of muscular action with resulting fracture are found in accidents 
which are caused by great muscular exertions failing to meet the 
resistance expected. Excessive force in throwing an object which 
slips from the grasp may result in fractures of the humerus from the 
powerful action of the shoulder-girdle muscles. Likewise in kicking 
violently at an object and missing it, one may fracture the femur. 
In violent efforts of running with a misstep or slip, muscular action 
may pull off the lesser trochanter of the femur. The bones involved 
in these fractures are generally healthy and are those of robust adults. 
No abnormal changes in their structure are necessary, and this type 
of fracture is frequently found in routine Roentgen-ray examination. 
Muscular action may be combined with direct or indirect violence 
by being brought into play to resist stresses applied to a limb and 
become a contributory cause of fracture. The addition of muscular 
action may greatly increase fracture violence and its continuance 
afterward augment the displacement and local symptoms. It may 
also act in connection with pathologic conditions, as previously 
described, causing the final solution of continuity in a bone already 
weakened bv disease. 



GENERAL MECHANISM OF FRACTURE. 

From a mechanical standpoint fracture can be explained on the 
basis of stresses and strains. This explanation is not easy to apply 
to clinical work, but is a suitable division of exciting causes. Trauma 
of accident or injury results in stresses transmitted to the supporting 
bones which can be analyzed into component compressive and tensile 
factors modified by various torsion, flexion, and shearing stresses. 
Combined with this elementary fact there are generally complicating 
shocks and vibrations like those caused in the jars of falls. These 
additional vibratory forces may produce rapidly alternating compres- 
sion and tension which prohibit a simple mecham'cal analysis. The 
vil)ratioiis break and modify a bone when it is under severe strain 
of bending or torsion — almost at the ])oint of giving way. '^i'his 
mechanism can be reduced to sim[)le terms by comparing a long bone 



46 



ETIOLOGY AND MECHANISM OF FRACTURE 



subjected to direct violence, with a beam supported at both ends, 
carrying a load between. This has been explained by Rixford,^ Pringle 
and others. Compressive stress made on the beam, i. e., bone, on the 
side of the application of the load is equivalent to direct violence, 
the maximum force being expended at the point of application. This 
acts by compressing the beam at that point, while at a point directly 
opposite, supposing the force is acting at right angles to the long 
axis, there is a corresponding point of maximum tensile stress that is 
tending to tear the structure apart (see Figs. 6 and 7). On account 
of their structure long bones usually give way from tensile rather 
than from an equal compressive stress. Fracture by direct violence 
may be indicated schematically by Figs. 6 and 7. The usual line of 
fracture in a beam, even steel beams, is not exactly transverse, because 
the beam bends and gives way as the fracture progresses through its 
substance. This bending increases, and finally in the course of the 
fracture a point is reached where resistance to tensile stress in the 
transverse diameter is equal to or less than the tensile stress resistance 



U...... ■..:../...,. 




Fig. 6. — Illustration of direct violence applied 
to a beam in the transverse and in the longitu- 
dinal axis. 




Fig. 7. — Result of direct com- 
pression on a beam. The planes of 
separation are frequently oblique, 
the small fragment being broken 
out on the side of application of the 
violence. 



in the longitudinal axis, and the fracture line takes an oblique direction 
(see Fig. 8) . If these two lines of fracture develop, they diverge from 
this point of application of force and the beginning point of fracture 
separation on the convex side of this bending curve. They pass 
toward the concave side, and as a result a triangular-shaped piece, 
like a wedge with its base on the concave side of the bend, is broken 
out. This wedge may be comminuted into several pieces and confirm 
Bardenheuer's observation that the loose fragment is always on the 
side of the concavity of the deformity. Both these diverging lines of 
fracture may not be complete; one may be a mere fissure with no 
separation, a case in which the fracture becomes a true oblique fracture 
caused by })ending or flexion of the bone. These are seen in the 
humerus and femur, the line starting at the tuberosity and passing down 
and inward ol)Hquely, and are caused by flexion over some object 
used as a fulcrum, as a heel in the axilla during attempted reduction. 
Another variation is sometimes found in cases where the transverse 



1 Jour. Am. Med. Assn., Ixi, 916. 



GENERAL MECHANISM OF ^RACTURE 



47 



cohesion or tension strength resistance is low compared to the longi- 
tudinaL A mild bending of the bone may cause a longitudinal split 
or separation with both ends of the fracture line opening on to the 
concave side, the broken piece being pushed or squeezed out away 
from the shaft of the bone (see Fig. 9). Occasionally a direct, sharp, 
quick blow with bendmg results in a completely transverse line of 
fracture. If these fractured ends are examined, incomplete diverging 
fissures will be found which run upward and downward along the 
bone from the transverse fissure. These lines obey the mechanical 





Fig. S. — Fracture of both Vjones 
of the leg from direct compressional 
x-iolence. Note the oblique planes 
forming and the loose fragment 
broken out. 



Fig, 9, — Direct compressional violence ap- 
plied to the tibia resulting in fracture with 
longitudinal splits opening on to the concave 
side of the bending bone. A piece is squeezed 
off the shaft at this point. 



law expressed above, and they always seem to take origin at that 
side of the bone which corresponded to the convexity of a curve 
produced by the force. 

Pure flexion fracture results from a direct violence applied at right 
angles to the bone shaft. If the force is not perpench'cular, l)ut comes 
from an angle, torsion and twisting are introduced into the mechanism. 
Mexion fracture may also be caused indirectly by two forces acting 
at opposite sides of the bone shaft, one at each end. ""JVo forces acting 
on opposite sides of the same le\el produce a comminuted fracture with 



48 



ETIOLOGY AND MECHANISM OF FRACTURE 



I 






little displacement, but if one force acts on a slightly higher level than 
the other, a transverse fracture with lateral displacement results. This 
has been called a shearing fracture (Fig. 10). The best example of 
this shearing type is found in the talus. Falls on the hyperflexed 
foot cause the sharp anterior articular edge of the tibia, driven by the 
momentum of body weight, to cut off the head of the talus. The body 
of the bone is crushed and pushed out backward, the sheared off head 
finding displacement anteriorly. 

Green-stick Fractures. — ^It has always been considered that chil- 
dren's bones, because they were softer and more elastic than adult 
bones when subjected to bending strain, would split partly in the 
transverse axis and then suffer longitudinal cracks and fracture with 

further bending of the unbroken portion on 
the concave side. This is the type of frac- 
ture found in green wood with a longitudinal 
grain. As a matter of fact, however, this 
type of fracture is very rare even in chil- 
dren, because the lateral cohesion of bone 
is relatively large, and although most frac- 
tures of children's long bones are caused by 
bending they are not incomplete fracture 
across the transverse axis. Most of them 
are complete fractures, transverse or oblique, 
the ends are splintered by the incomplete 
fissures previously described, and the dis- 
placement is usually only angular. Some 
are buckling or compression fractures of one 
side of the shaft, if the force is expended 
in a longitudinal direction only or is not 
sufficient to cause any more cracks or carry 
its lines of separation to the concave side of 
the bend. We know that the compacta 
causes rigidity and stiffness in long bones. 
Children's bones have a thin compacta which 
does not extend as far toward the articular 
ends as in adult bones. The cancellous 
tissue extends farther from the epiphyses in children also, and it is in 
this area of cancellous bones with a very thin compacta that the bone 
breaks incompletely by buckling on the side subjected to the greatest 
compressive stress. Of 17 incomplete fractures of the radius and ulna 
recorded by Rixford 8 were typical buckling fractures, one to one and 
a half inches above the epiphyseal line ; 6 buckled on the dorsal and 2 
on the volar surface. Epiphyseal separations are always due to tensile 
stress, which pulls them off by means of ligamentous insertions, the 
area being too soft to break. 

I3uckling occurs in the radius and humerus most frequently. I have 
a roentgenogram (Fig. 11) of one rare case of buckling fracture from 
longitudinal compression, apparently involving the whole circum- 



FiG. 10. — Shearing fracture 
in the femur. Transverse with 
lateral displacement. 



GENERAL MECHANISM OF FRACTURE 



49 



ference of the upper end of the shaft of the humerus. Rixford says the 
only true green-stick fracture he ever saAv was in a man aged twenty- 
eight years. I have seen one in a man aged forty years. Children's 
bones are tougher and more elastic than the brittle bones of adults, 
the periosteum is thicker and more yielding, and there is generally a 
thicker pad of subcutaneous adipose tissue to take up jars. If applied 
violence is sufficiently strong, transverse fractures occur in children 
as well as in adults. If the force is not sufficient to cause complete 
fracture, the child's tough and elastic bone yields, and the process 
ceases when it reaches a point short of complete separation, the 
splmtered fragment ends interlocking and preventing lateral or 
rotatory displacement but permitting angular displacement. This may 
occur without rupture of the periosteum on either side of the bend, 
but the fracture is not a green stick break, 
rather a subperiosteal fracture. Roent- 
genograms of so-called green-stick fractures 
after healing show callus formation on both 
the concave and convex, or greater separa- 
tion side, verifying the transverse solution 
of contmuity.^ 

Familiarity with green-stick fracture has 
practical importance in treatment. Because 
these fractures are complete and not green 
stick, do not manipulate them and produce 
more displacement by increasing the angu- 
larity, but simply press them back into 
alignment. A true green-stick fracture will 
have shortening from compression on the 
concave side, and it should be broken clear 
across by exaggeration of the angular 
deformity, but the periosteum must not 
be ruptured in the process. It acts as a 
guard to hold the osteoblasts within the 
bone contour. 

Fractures Caused by Torsional Violence. 
act on a limb in two ways. It may be applied at the periphery of the 
limb, the proximal portion remaining fixed, or the peripheral portion 
may be fixed and the torsion applied through the proximal portion. 
The common examples of these mechanisms are seen in the leg. The 
leg is fixed and the foot is twisted outward, the torsional violence 
being applied at the periphery. The foot is fixed and the body is 
twisted and swung around transmitting torsional stress to the upper 
part of the leg, i. e., the peripheral portion is fixed and torsional 
violence applied to the proximal portion (see Fig. 12). These mechan- 
isms result in spiral fractures, not oblique fractures, which are really 
rare and occur from direct compression violence, as previously described. 




Fig. 11. — Buckling fracture 
involving the whole circum- 
ference of the upper humeral 
shaft, caused by longitudinal 
compression. 

-Torsional violence may 



1 Cotton, Bost. Med. and Surg. Jour., November 29, 190G, p 553. 



50 



ETIOLOGY AND MECHANISM OF FRACTURE 



Oblique fractures have the angular points of the fragments on opposite 
sides of the bone; spiral fractures more frequently have the points 
on the same side, and in the case of the tibia on the rear surface. 
Spiral fractures result most often in the leg, then in the femur, then 
in the humerus, etc. The humerus suffers less frequently because 
dislocation occurs many times at the shoulder before the shoulder- 
point is fixed to permit spiral fracture of the bone. In the forearm 
also the bones are more readily dislocated than fractured spirally. 

Kocher and Zuppinger,^ and Zuppinger-Christen^ first explained this 
mechanism. The shaft of a long bone is comparable to a hollow 
cylinder of nearly uniform construction (Fig. 13). When such a 
cylinder is subjected to axial torsion beyond the point of elastic limit 
it breaks, and the line of fracture is a spiral. The spiral takes the same 

direction as the torsion; that is, spiral 

/^ fracture is either right- or left-handed. 

When the axial torsion is applied, tensile 
stresses develop on the outer surface of 
the cylinder which are counterbalanced 
by compression stresses on the interior 
surface as long as the torsion does not 
overcome the limit of elasticity. When 
the bone breaks, the line of separation 
extends along and around the shaft in 
spiral form and may pass once or twice 
completely around the circumference (see 
Fig. 14). As the bone gives, starting 
from some weak point it tends to unroll 
in its longitudinal continuity, and as it 
does the tensile stress is shifted to the 
inner surface of the cylinder and the com- 
pression stress passes to the center (Fig. 
15). As the spiral or screw fractures 
proceeds in its unfolding along the bone, 
flexion becomes a factor. The force of 
torsion loses some of its effect, and the flexion combined with it 
causes a longitudinal line of fracture connecting the spirals. As 
a rule, in the tibia the spiral separations are on the anterior surface 
of the bone, both on the same aspect, and the longitudinal line is on the 
posterior surf ace, so that each fragment ends in a sharp or wedge-shaped 
point, the two lying vertically one above the other. This differs 
from the true oblique fracture described previously. The spiral line 
may continue as an unseparated fissure beyond the ends of the frag- 
ments. On account of greater elasticity the line of spiral fractures 
in young bones is steeper and longer than in old bones (Fig. 16). 
Increased spiral pitch is also found in small bones as compared with 
large. At the site of the spiral separations the periosteum is always 

1 Beitr. z. klin. Chir., 1906, p. 301; 1909, p. 562. 

2 Allgemeine Lehre von den KnochenbriJchen, Leipzig, 1913, p. 26. 




Fig. 12. — Affect of torsion on 
the leg when the body is twisted 
and the foot is fixed. Adapted 
from Zuppinger. 



GENERAL MECHANISM OF FRACTURE 



51 



torn apart. It may remain intact in the longitudinal portion of the 
fracture, unless there has been additional longitudinal force, which 



^^ 




Fig. 13.— Arrows 
indicate the direc- 
tion of torsional vio- 
lence applied to a 
hollow c 3' 1 i n d e r 
likened to a pipe- 
stem bone. 



Fig. 14. — The spiral manner of 
separation from torsional vio- 
lence. The two points of the 
fragment lie vertically one above 
the other on the same surface of 
the cylinder. 



Fig. 1.5. — Pure spiral 
fracture in the humerus. 
Note the rotary dis- 
placement. 



Fig. 16. — Incomplete spiral fracture 
of the tibia of a young person. 



Fig. 



17. — Steep spiral fracture of the 
tibia. 



produces shortening and strii)ping up or tearing. Clinically s})iral 
fractures are rarely of pure type, because many are received while 



52 ETIOLOGY AND MECHANISM OF FRACTURE 



1 



the }){itieiit is standing. Longitudinal force of weight-bearing and 
niuscuhxr action may continue to act after the torsional violence has 
eased off and may cause periosteal stripping, comminution, or an 
open fracture, by driving the pointed fragments out through the soft 
parts. The flexion action which begins as the leg loses support (Fig 17) 
from the spiral separation, may cause a quadrilateral-shaped piece 
of bone to be pressed or squeezed out on the concave side. Pringle 
says this piece is entirely comparable to the triangular piece of bone 
found on the concave side in a flexion fracture. In the leg the fibula 
may also be broken or not. This depends on the degree of torsional 
violence and the elasticity of the fibula. Consequently in young 
individuals we would not expect the fibula to be broken often. If 
it is broken by torsion, a spiral fracture above the line in the tibia 
is expected ; if it breaks because of flexion after the tibia has given way, 
we may look for the transverse or oblique fracture. Spiral fracture 
of the fibula alone does not occur except in the external malleolus; 
it is caused by torsional violence from external rotation of the foot 
and ligamentous pull. 

In the chapter on Fracture of the Bones of the Leg attention is 
directed to the finding that spiral fractures are usually left-handed 
in the right leg and right-handed in the left leg. This same observation 
can be made of spiral femur and humerus fractures, the cause existing 
in the fact that the foot or forearm, the mobile peripheral portions, 
project forward and outward and in injuries are more exposed to 
outward rotation. The other leg tends to prevent inward rotation, 
and the forearm by striking against the trunk acts the same way in the 
upper extremity. Consequently this rule holds, whether the peripheral 
segment of the limb is turned outward upon the fixed proximal portion, 
or the "peripheral segment is fixed and the trunk becomes mobile and is 
rotated in the opposite direction. Right-handed spiral fractures in a 
right extremity could occur only under the rare conditions that the 
peripheral segment was rotated inward contrary to ordinary mechanism 
or the peripheral portion was fixed and the mobile proximal portion 
was rotated outward. 



CHAPTER III. 
PATHOLOGY OF FRACTURE. 

I. Thr Bone. 

Types of Fracture: 

1. Complete, subdivided according to— 

{(t) The plane of fracture, into transverse, oblique, spiral, longitudinal, 
comminuted and V-, Y-, and T-shaped. 

(b) The site of fracture, into shaft (diaphyseal), neck, epiphyseal, inter- 

or supracondyloid, malleolar, intra-articular, fractures, sprain 
fractures, and splinter separations. 

(c) The displacement, into transverse, angular, rotator5% overriding, 

impacted, longitudinal, and crushed. 

2. Incomplete, subdivided into — 

Green-stick or true incomplete fracture, fissures, depressions, punctures, 
and buckling. 

3. Closed and open fractures. 

4. Multiple fractures, involving the same or different bones. 

5. Gunshot fractures. 
II. The Soft Parts. 

III. Complications axd Sequelae. 



I. TYPES OF FRACTURE. 

1. Complete Fractures. — All fractures may be divided in accord- 
ance with their local pathology, as they are usually a manifestation of 
trauma, or of indirect violence, and do not depend on constitutional 
disturbance. Complete fractures are those in which the bone fragments 
are separated by a plane crossing through the bony substance. 

(a) Plane of Fracture. — The direction of the plane offers a mechanical 
subdivision. The direction may be transverse, oblique, spiral, longi- 
tudinal, comminuted, and V-, Y-, or T-shaped. In the chapter on 
Etiology and ^Mechanism an attempt has been made to explain some 
of these planes of. fracture from a physical standpoint. Uncomplicated 
examples of these various direction planes are not common. As we 
have seen, the lines of force become complicated as a bone gives 
way under breaking compression and tension force, and the result 
is the formation through the osseous tissue of new lines or planes 
complicating the original plane. Transverse fractures are those 
which correspond within a few degrees to the transverse axis of hone. 
Oblique fractures are those the plane of w^hich passes through the 
bone at an angle from 40 to 70 degrees. There may be two planes, as 
flescribed previously, with the breaking out of a pyramidal-shaped bone 
fra^m.ent. Simple obHque fracture is not common. Either one of these 
two varieties may show a rough and splintered surface when the frac- 
ture site is opened or when a roentgenogram is studied. If the whole 
plane of separation is irregular with many })rojections, it is called 
toothed or dentate. 



54 PATHOLOGY OF FRACTURE 

Spiral fractures occur iu long bones. The tibia, fibula, femur, and 
humerus are common sites, and the cause is torsional stress. From 
an undcM'standino- of the mechanical causes of torsion or spiral fractures 
we know that the usual plane of separation of the spiral is right-handed 
in the bones of the left extremities and left-handed in the right ex- 
tremities. The planes of fracture as a rule in pure torsion fracture 
start and end on the same surface of the bone, differing from oblique 
planes, which start and end on opposite surfaces. If compression and 
torsional stress are combined in the cause, one may expect irregular 
planes of fracture, or comminution. 

Longitudinal planes are an exaggeration of oblique planes. This 
form of traumatic bone separation is rare. They are found when a 
limb has been subjected to great violence as falls from a height or 
a splitting force applied in the axis of the chief lamellse. In many 
instances they are complicated by crushing and impacted conditions 
of the bone at the joints. The separation of fragments varies; usually 
it is not great and runs off at one end into a fissure of incomplete 
fracture. Wide separations are troublesome; they are difficult to 
reduce, and the subsequent thickening of the bone leads to complica- 
tions which interfere with the function of the limb. 

Comminuted fracture is the term applied to a bone broken in several 
pieces. In addition to having a distinct plane of separation which 
represents the major action of the force, the bone in the vicinity is 
broken up or splintered by the action of the combined stress. Com- 
minution is a term also applied to fractures of flat bone, like the scapula 
or the vault of the skull, when several irregular large fragments are 
broken off or out of the bone. There may be no splintering or crack 
coexistent. 

The terms V-, Y-, and T-shaped are applied to fit the shape of a 
broken out fragment, or the direction of the plane of separation. 
V-shaped fractures are found in the shafts of long bones and are due 
to compressional violence (see Etiology and Mechanism). Y- and 
T-shaped fractures are found near and into joints. 

(6) Site of Fracture. — The site of fracture also offers a basis for sub- 
division. For convenience one often labels the fracture according to 
the part of the bone involved, and as any part of the osseous structure 
may suffer complete separation there is a corresponding nomenclature. 
There are fractures of the shaft, neck, malleolus, inter- or supra- 
condyloid between or above the condyles of the humerus and femur. 
Sprain fractures, which are caused by the pulling out of strong muscle 
of ligament insertions, are usually near joints. They may affect any 
bone with these insertions, and are often so minute and delicate that 
they can be made out with difficulty. They are, however, real solutions 
of bony continuity and require sufficient protection and rest to give 
time for bony union. 

Splinters may be separated by direct violence from parts of the 
bone, either near the articular ends or from the shaft. Direct violence 
and ligamentous pull tear these off, and the displacement may be very 



TYPES OF FRACTURE 55 

wide. Examples of tearing separation are furnished by fractures of the 
tuberosities of the humerus, the iliac spines, the trochanters of the 
femur, and other points subject to great muscuhir strain. The separa- 
tion varies (see illustrations of these mentioned examples). 

Articular fractui-es are those in which the plane of separation in 
some parts of its course enters into a joint. The separation is of varying 
degree and consequence. A fissure through the bone substance may 
continue from a fracture plane near a joint, pass through the bone, and 
stop just under the cartilage and synovial surface. Strictly speaking 
this would not be an articular fracture, but for all practical purposes 
it is so. In more pronounced cases there is a splitting apart of the 
joint end of the bone, tearing the joint surface through and resulting 
in a hemarthrosis, without tearing the joint capsule. A final stage is 
represented by T-, and Y-fractures found in the lower end of the 
humerus and femur, in which articular fragments are broken off and 
pushed asunder, with wide tearing of the joint capsule and a driving 
down of the broken shaft into the disrupted joint. Intra-articular 
fracture is a term which should be applied in a limited sense to solutions 
of bone continuity taking place entirely within the joint. Fractures 
of the femoral neck within the capsule, of the olecranon and patella, 
of articular portions of bones like the femoral and humeral con- 
dyles, are in this division. Fractures of the carpal and tarsal bones 
which really lie within a joint must be included in this division 
when their pathology is studied. (See drawing representing schematic 
arrangement of synovial surfaces under the heading of Wrist Frac- 
tures.) 

The pathology of intra-articular fractures concerns the joint struc- 
tures as much as the articular fractures. The capsular ligaments 
may not be disturbed, or they may be widely torn. Likewise, there 
may be hemarthrosis, aseptic inflammation, and joint distention, infec- 
tion, and pyarthrosis. The turning of a fragment or a small amount 
of excess callus, the contraction and implication of periarthritic 
structures may interfere seriously with joint function. The broken- 
off bone fragment may be absorbed by pressure or action of the synovial 
fluid, or its presence may prolong the periarticular irritation and loss 
of function. This is particularly true in many carpal and tarsal 
fractures and is not a widely known pathological fact. Intra-articular 
fragments may mechanically interfere with joint motion from the 
time of accident, or, by reattachment to bony or capsular surface, at a 
later period. The articular fractures are those which enter the opera- 
tive class at the very first, and with an understanding of their pathology 
the surgeon may often make a decision for early removal of fragments 
or of a whole bone, rather than delay until periarticular changes and 
prolonged disability demand open operation. 

Epiphyseal separations are now known to be an every-day occurrence. 
They are found in any bone from the femur to the phalanges and 
must be considered in all differential diagnoses of fractures near 
joints. The plane of separation is usually through the cartilaginous 



56 PATHOLOGY OF FRACTURE 

area of the i^'rowing' ei)i])hysis, although these separations are present 
up to the time of complete ossification of the various epiphyses. 
After calcification a plane of fracture is likely to select the old epi- 
])hyseal region, if the stress a})plie(l is cross pulling and twisting near the 
ligamentous insertions around joints (see Fi^actures at the Wrist, etc.). 
A ragged edge marks the disjunction of the epiphysis from the diaphysis 
and the plane of fracture in complete separation frequently varies to 
extend a short distance through the diaphysis. 

Separations may be complete or incomplete. The epiphyseal plane 
may start to separate along one edge of the bone and cease before the 
whole diameter is involved, or the fragments may be but slightly 
started from their position and have an inconsequential separation. 
Complete separation with sliding of one fragment over the other is 
also of different degree. When there is shifting, the periosteum is 
ripped up from the diaphysis for some distance. It may retain its 
attachment to the epiphysis and move out of place with it, or it may be 
torn across and left lying in natural contact with the shaft. I do not 
believe torn periosteum ever seriously interferes with reduction of 
epiphyseal separations by interposition. The diagnosis is not difficult 
clinically in the ends of long bones. In the neck of the femur its 
decision may be impossible without a roentgenogram. The cases are 
characterized by displacement in the vicinity of a joint, or of a known 
epiphyseal plane. The joint prominences themselves are intact. 
There is no crepitus, and the swelling and tenderness lie at the epiphy- 
seal site. A perfect reduction of an epiphyseal separation gives a 
correspondingly good prognosis. There are a few cases in the literature 
which have caused interference with growth of a long bone, but when 
one compares them to the great number of epiphyseal separations 
which occur, there seems to be little danger of interference with growth. 
I have several epiphyseal separations at the wrist and ankle under 
observation and have never seen a case of growth disturbance. 
Theoretically one might expect infections and abscesses to follow these 
injuries, because organisms in the blood stream would tend to settle 
and thrive in the traumatized area. Clinically this is not so. Under 
the heading of each bone discussed some attention is drawn to the 
various epiphyseal planes and the frequency, causes, symptoms, and 
treatment of their separations. 

(c) Displacements of Fractures. — The types of fractures are also 
divided according to the character of the displacement of the important 
fragments. These displacements are transverse, angular, rotatory, 
overriding, impacted, and longitudinal. There is also longitudinal 
crushing or buckling. There may be various combinations of these 
pathological states. It is usual to find rotatory displacement associated 
with other forms, because body weight acts in the mechanism after 
violence has caused a solution of bone continuity. The pressure of the 
body on a limb results in torsion stresses from muscular pull when the 
normal bony support within the part is lost. Likewise overriding and 
impaction may be combined. 



TYPES OF FRACTURE 57 

Transverse displacement is a lateral shifting of the fractured surfaces 
on each other so that their long axes do not coincide. This change 
may take place in any direction toward either side or backward or 
forward. It is incomplete when the fractiu'cd ends are shifted hut not 
completely separated. (Tcnerally there is complete separation, and 
the fragments have an angular deformity or ride past each other. 

Angular displacement is shown by the formation of an angle at the 
site of fracture by the axes of the two main fragments. This angle may 
be of any degree up to 90, and the fragments may come to lie one 
against the other, forming a right angle. The whole amount of angular 
displacement is not caused by the fracture violence as a rule. Gravity, 
body weight, and muscular action add their effect after the bone 
separates. 

Rotatory displacement signifies that the fragments turn on each 
other in their long axis. As described in the chapter on Mechanism 
of Fracture, this rotation in an extremity usually concerns the distal 
portion which is turned outward and at the fracture site the distal 
fragment is usually the one rotated, although both may be rotated 
when unbalanced muscles come into play after the fracture of the 
bone . 

Overriding of fragments past each other is caused by body weight 
and muscular action after transverse, oblique and spiral fractures. 
Hemorrhage and traumatic swelling within the tissues may increase 
the displacement. The continuance of the force in falls on an extremity 
or torsional violence may also produce overriding and it is difficult 
to analyze the different factors. In cases of extreme overriding all 
three factors undoubtedly come into action. The pathology in this 
condition is more extensive than in fracture with less displacement. 
The periosteum is torn or stripped up, muscles and fascial sheaths 
are ruptured, there is more hemorrhage. 

Spiral fractures with overriding lead to fractures opened to the air 
from within by sharp points of bone. 

Impaction displacement signifies complete fracture wdth an imme- 
diate subsequent ramm.ing penetration of the fragments whereby 
they are driven together and the bone lamellae are crushed into each 
other. During the momentary separation the axes of the fragments are 
usually changed so that when the portions are united by impaction 
there may be angularity or transverse displacement. 

Longitudinal displacements are of two kinds. One is complete and 
concerns separation found in fractures of the patella and olecranon. 
This kind is caused by muscular and tendinous contraction, by swelling 
of tissues, and by the distention of joint cavities by blood. The 
second type of longitudinal displacement is incomplete and may be 
described as a crushing or telescoping of the bone in its long axis. 
Some lamellae are crushed into each other, others are forced out at a 
wide angle from the former axis, and the bone is shortened in its 
longitudinal axis. This type of fracture is sometimes called a buckling 
fracture. See remarks on mechanism of fracture. 



58 PATHOLOGY OF FRACTURE 

2. Incomplete Fractures. — Incomplete fractures are divided into 
true incomplete or green stick fracture, fissures, depression, punctures, 
and hucklin^' fractures. 

Green-stick Fractures. — (ireen-stick fractures have been discussed 
in the chapter on Etiology and Mechanism of Fracture. The bone is 
separated by a spHntering on the concave side of the bend induced 
by violence, the other side suffering no change at all or a slight com- 
pression. True green-stick fracture is rare and is replaced by being 
pushed back into alignment. Healing rapidly follows, and there is no 
displacement and deformity. Infraction is a term also applied to this 
type of bone bending. It illustrates fully the mechanism of bending 
fracture. There is a small transverse line of fracture or separation 
accompanied by multiple longitudinal lines which pass into the long 
axis of the bone. The periosteum is seldom ruptured. There is some 
swelling at the site of fracture from the interstitial hemorrhage and 
distention of the periosteum. 

Fissures. — Fissures in the bone are closely allied to green-stick 
fracture. They are long cracks in the bone substance without much 
displacement. These fissures may be oblique, spiral, or longitudinal. 
In long bones they are seldom found alone but usually in connection 
with complete fracture, some of the extended lines of force splitting 
open the distant portion of the shaft. The periosteum may be torn or 
not; over the fissure area it is generally uninjured. Isolated fissures 
are seen in long bones, in the tibia and humerus. They are character- 
ized by pain, soreness, and loss of function, out of proportion to physical 
findings of the bone concerned. There is no displacem.ent, crepitus, 
or deformity, and the full extent of the crack can be determined only 
by the roentgenogram, although the extent of the persisting line 
of tenderness furnishes a clinical basis for measurement. Fissures 
opening into joints frequently cause hemarthrosis distant from a 
fracture site. They are important in cases of operated fracture, as 
they may interfere with the application of internal splints. In skull 
injuries, fissures are of great importance. A large percentage of 
basal fractures are fissures, the bone lesion being of little importance, 
the hemorrhage consequent to the slight bone separation from torn 
vessels having much significance. The slow oozing and gradual 
increase of intracranial pressure interferes with cerebral function, 
results in edema and coma, and may lead to a fatal termination. 
Fissure in the pelvic bones may also be of significance on account of 
the contained viscera. 

Depressions and Punctures. — Depression is the term applied to a 
limited area of crushing which involves the surface of a bone and does 
not form a complete plane through its substance. Small depressions, 
usually linear in character, can be found on the broad surfaces of the 
tibia, or on the enlarged ends of bones like the femoral condyle. They 
are caused by direct violence, the compact layer is depressed into 
the medullary portion beneath, the harder compact surface retaining 
its form while the trabeculse of the medulla are crushed to permit the 



TYPES OF FRACTURE 59 

displacement. Depressed fractures of the skull illustrate this con- 
dition. The presence of the spongy diploe permits the outer table to 
be broken down and depressed below the surrounding surface without 
injury to the inner table. Both tables may be involved. These 
fractures are frequently spoon-shaped or circular. 

Puncture fractures are caused by the impact of a sharp point which 
is driven down into the bone substance. Pitchfork points, bayonets, 
knife blades, or bullets, are examples. The outer surface of the bone 
first struck may be depressed by the object and carried down into the 
mass of bone. The pathology is usually a separation of the bone 
trabeculse which permits the object to pass within or possibly through 
its substance. If the puncture is simple, it heals promptly. It may 
lead to deep infection in the bone or cause splitting and comminution 
for some distance. 

Buckling fractures have been described previously under the 
pathology of complete fracture and in Etiology and Mechanism. 

3. Open and Closed Fractures. — A division of fractures is made on 
the basis of the presence or absence of a wound in the skin and soft 
parts which leads to the fracture. A wound of the soft parts overlying 
the broken bone is caused by violence from without or puncture of the 
parts by a sharp fragment of bone from within. These fractures 
have been called compound and simple. The terms open and closed 
are more specific, they are intelligible to laymen, and their simplicity 
has led to their adoption. In 10,702 fractures at the Cook County 
Hospital which I have studied there were 379 open fractures. 

A closed fracture has considerable local pathology. It means 
injury and loss of continuity of the osseous tissue and to a certain 
extent injury to surrounding soft parts. There are blood extrav- 
asation and the phenomena of aseptic inflammation. Closed fracture 
may become open fracture in a few days, if the soft parts become 
gangrenous and slough, or if a splint unwisely applied presses against 
the swollen tissues and causes the same result. Open fractures may also 
occur in the course of repair of closed fracture, if the patient becomes 
delirious or unruly and throw^s the limb about, opening the soft parts 
by projection of a bone fragment from within. Open fracture conveys 
the idea of an opening or wound through the tissues covering the bone. 
Such an injury contains all the pathology of a closed fracture, and in 
addition invites primary infection from the causative trauma, or 
secondary infection from the access of air and external dirt through 
the skin to the depths of the wound. Any fracture with loss of skin 
continuity, even though it is not immediately over the site of bone 
injury, must be considered as an open fracture. It is impossible 
to say whether the opening in the soft parts leads indirectly to the 
bone lesion, and in many instances it is unwise to probe to ascertain 
this connection. The soft parts may break at a different level; the 
intervening clot which forms may partly drain out and partly act as a 
barrier to prevent deep infection. In some instances, especially when 
the soft parts are wounded by a fragment penetrating from within 



GO PATHOLOGY OF FRACTURE • 

outward, conservative treatment of non-interference is the best, 
because there is less opportunity for infection in injures of that type. 
(See Treatment of Open Fractures.) Tlie shock of open fracture is gen- 
erally greater than that of closed. Hemorrhage may in part account 
for the difi'erence. A certain proportion of open fractures, more often 
those opened from within, heal as rapidly as the closed fracture. 
The drainage of the hematoma about the fracture site, in the absence 
of infection, favors early union. This point is discussed in the chapter 
on Bone, under the heading of the Healing of Open Fractures. In the 
chapter on Treatment, the question of and indication for amputation 
and operation are considered at length, and under the heading of each 
bone specific open fractures are discussed. 

4. Multiple Fractures. — Single fracture is a term rarely used. 
Multiple fracture is a term applied to two conditions. The same 
bone may be broken in more than one place with no connecting plane, 
or tw^o or more bones may be broken simultaneously, although at a 
distance from each other. When a bone is broken in two or three 
places the condition is often called double or triple fracture. Extensive 
comminution of a flat bone like the scapula or fracture of several ribs 
is called multiple fracture. Usuall}^ multiple fractures are more serious 
than single fractures, because they are the effect of a greater violence 
and the cause of greater shock. Consequently the prognosis varies 
with the multiplicity of the breaks, not so much on account of the bone 
lesions as on account of the increased shocking effects. A dozen 
fractures in different parts of the body will heal as quickly as a single 
fracture, if the patient overcomes the primgiiry shock of injury and 
possesses no constitutional or local reasons for delayed union. 

5. Gunshot Fractures. — Gunshot fractures are really a division 
of open fractures caused by bullet wounds. They are a well-defined 
type, and though they are subject to all the pathological conditions 
of ordinary open fracture, they are also for some reasons a favored 
class. Bone destruction is minimized by the modern high-velocity 
bullet. When this bullet strikes on the edge or flat surface of bone, 
it may burrow it or break off a spicule, but it does not spxead like 
soft-nosed bullets and rarely causes great comminution of the osseous 
structure. Striking in line wdth the transverse axis of a bone it may 
cause a transverse fracture, or may penetrate it cleanly, leaving a small 
opening, or cause a slight degree of comminution. If the bullet 
traverses the longitudinal axis of a bone, it causes extensive comminu- 
tion. Bullets nearly spent may strike a bone and fail to cause a 
complete fracture. Splits and fissures or breaking off of shells from 
the surface are common results. After it has been injured in this 
way a long bone may break under the strain of use. 

From a pathological standpoint the greatest interest lies in the 
accompanying injuries of the soft parts. Infection in the bullet 
track stands out as of foremost importance in regard to prognosis 
and treatment. Since the inception of the war of 1914 many eminent 
surgeons have spoken on the treatment of gunshot fractures. Goebel 



THE SOFT PARTS 01 

classes all infections which are not received from the bullet itself 
as secondary, the bullet alone causing primary infection.^ This is 
contrary to the opinion of many other men. Many gunshot fractures, 
particularly those caused by a pistol in civil practice, are relatively 
clean and do not often lead to serious infections. At the Cook County 
Hospital we receive many gunshot fractures, and there have been no 
amputations for infections from this source in two years. In war 
there is a large proportion infected, and first treatment must be 
directed toward combating the infection. Drainage and a minimum 
amount of operative interference with immobilization are indicated. 
Mr. Robert Jones- decries any attempt to use internal fixation in gun- 
shot fractures, and advises immobilization in splints like the Thomas, 
or slings for the arm which permit free drainage, and he does not 
employ a plaster encasement which becomes fouled with discharges. 
Chaput,^ Bonnette,^ Korundjy^ and Watson^ give descriptions of 
methods of improvising splints for gunshot fractures in different parts 
of the body and also of methods for after-treatment. 

Fractures caused by shots from shotguns at close range are serious 
on account of the injury of the soft parts. I have had three cases in 
the last six months, one of the humerus and two of the pelvis. All 
three had a fatal termination from complications and sepsis of the 
soft parts. Immediate amputation might have saved the arm case, 
but it did not seem advisable, because there was no nerve injury and 
the circulation of the arm was satisfactory, although the bone was 
blown to bits. Gunshot fractures of the skull are considered in the 
chapter on Skull Fracture. 

In civil practice gunshot fractures from bullets do not give a greater 
mortality than open fractures from other causes, and they frequently 
heal quicker and have fewer complications. The subject of fracture 
caused by shell fire or shrapnel is not entered into here, because the 
injury in those cases is one of the soft parts primarily. Text-books 
of military surgery cover these points. 

Pathological fracture is discussed in the chapter on Etiology. 

n. THE SOFT PARTS. 

Fractures sometimes occur without injury of the soft parts. The 
femoral neck may be broken within the limits of the capsular ligament 
with no injury of the soft parts. Ordinary fracture of any bone, 
however, is accompanied by pathological conditions in the surrounding 
parts. Previous reference has been made to the fact that there may 
be a solution of bone continuity without tearing of the periosteum. 
This condition is present in green-stick fracture or infraction. The 

» Beitr. z. klin. Chir., 1914, xd, 373. 

« Brit. Med. .Jour., London, January 15, 191.5, No. 2820. 

3 La Presse Med.. September, 1914, No. 66. 

* Ibid., August 12, 1914, xxii. No. 62. 

* Ibid., August 26, 1914, No. 64. 

« Lancet, London, October 10, 1914, No. 4754. 



02 PATHOLOGY OF FRACTURE 

periosteum may be stripped up and loosened from the bone surface, 
or distended by hemorrhage from the ruptured osseous vessels and 
still maintain its continuity. This form of subperiosteal fracture is 
found in adolescents who possess a thick, resilient, vascular periosteum. 
The periosteum suffers every degree of laceration up to complete 
circumferential tearing, which is rare and found only in instances of 
great overriding displacement. Operative treatment of fracture has 
proved conclusively that periosteal shreds or bands between fragments 
persist in nearly every instance. 

Muscles, nerves, and bloodvessels surrounding a fracture site may 
similarly receive no injury, or they may be completely severed. In 
direct violence muscles and fascial sheaths are torn by compression. 
They may be injured by displaced bone fragments which puncture 
and lacerate them, causing loss of continuity and hemorrhagic oozing. 
Nerves and bloodvessels are likewise injured. Secondary results from 
these injuries are not frequent and are considered under the head of 
Local Complications. Pressure within a limb in a closed fracture, or 
tight bandaging and splint application, also lead to complications of 
the soft parts. 

The primary violence may rupture the skin or contuse it so that it 
sloughs and leaves an open wound. It may be punctured from within. 
In closed fracture, as the swelling follows from extravasation about the 
fracture, the skin becomes tense and shiny, as in inflammatory con- 
ditions. Its blood supply is diminished. Ecchymoses become apparent 
within two or three days, as the blood penetrates out toward the 
surface, and because this blood percolates along fascial and skin planes, 
a whole limb may show discoloration from fracture. Blebs filled with 
clear serum or deep colored blood are commonly found on the skin 
within a few days after fracture. They are so usual that they cannot 
be considered a complication. But by infection or sloughing they may 
result in serious complication, and by their presence they frequently 
preclude extensive splint application or operative treatment. 

III. COMPLICATIONS AND SEQUEL-ffi. 

Complications and sequelae are divided into general and local. 
General Complications. — Early: 

1. Pneumonia and pulmonary edema. 

2. Fat embolism. 

3. Delirium tremens. 

4. Tetanus. 

5. Shock and death. 

6. Sepsis. 

Late general complications: 

1. Postural and weight-bearing changes. 

2. Neurasthenical states. 

Early local complications: Lesions which involve muscle, including 
X'olkmann's contracture, nerves, and bloodvessels. 



COMPLICATIONS AND SEQUELJH 63 

Late local complications: 

1. Callus and displacement complications: 

(a) Excessive or painful callus. 

(b) Weak callus. 

(c) Delayed union. 

(d) Non-union and pseudarthroses. 

(e) Vicious union and deformitj^ 
(/) Nerve injury and inclusion. 
(g) Development of tumors. 

2. Arrest or exaggeration of bone growth. 

3. Neighboring joint complications, stiffness, reduction of motion. 

4. Muscle and soft part changes, stiffness, inelasticity^ fixation. 

5. Bloodvessel complications, thrombosis, embolism, and aneurism. 
Early General Complications. — 1. Pneumonia and Pulmonary Edema 

— Pneumonia and pulmonary edema are common complications 
of fractures. In the 10,702 fractures used as a basis for this book, 
there were 122 cases complicated by a lobar pneumonia, and 40 by 
pulmonary edema, as far as the clinical examinations could determine. 
Pneumonia may arise from exposure after injury, blows on the chest, 
or confinement in bed. Onset within the first forty-eight hours is 
usual, and the course is rapid, with a high temperature and general 
toxemia. This complication must be considered before anesthesia is 
given for early open operation or reduction of fracture by extension 
apparatus. The records of the Cook County Hospital are not in a 
condition which would warrant determination of the relative propor- 
tion of cases of pneumonia following the administration of anesthesia 
for operative and reduction purposes during the whole period of this 
series of fractures. Fat embolism plays little if any part in the 
production of pneumonia. (See Fat Embolism.) 

Pneumonia and hypostatic congestion or pulmonary edema are 
found as complications occurring within a period of four days to 
two or three weeks after fractures in elderly patients. I have seen 
one case starting in the seventh week. Confinement to bed and a 
recumbent position for fracture of any bone is the principal cause. 
The course may come on insidiously, with little fever and no cough. 
Prostration and delirium follow, and the patient may pass away 
quietly in a condition of great weakness. 

2. Fat Embolism. — Free fat may enter the circulation from the 
subcutaneous adipose tissue, the liver, or from the medulla of bone 
following traumata. It is a clinical fact that fat is found in the urine 
for two or three days after many fractures and it is possible that every 
fracture is followed l)y some injection of fat droplets into the general 
circulation by way of the veins or lymphatics. To cause symptoms or 
a fatal result the absorption of large quantities of fat is necessary. A 
sufficient amount cannot be found in tlie bones of youth under twelve 
or fourteen years of age. In adults when the medullary cavity which 
contains liquid fat is traumatized, a sufficient (juantity of fat may 
be thrown into the general circulation to cause fat embolism. Many 



64 PATHOLOGY OF FRACTURE 

cases of fat embolism have been reported by orthopedic surgeons "after 
bloodless manipulations for congenital dislocation of the hip. The 
bones manipulated under these circumstances have been out of function 
for a long time and have undergone degeneration in accordance with 
Wolff's law. We consider fat embolism after ordinary fracture to be a 
rare condition, but like many other conditions, it doubtless occurs 
more often than is suspected. It was formerly thought that there was a 
negative pressure within bones, or that the trauma of fracture caused 
an increase of pressure within a bone to such an extent that fat was 
sucked or pressed into venous capillaries, and passed into the venous 
circulation. We do know that fat is found after some fractures in 
terminal arterioles of the lungs, kidneys and brain, and the symptoms 
are supposed to be caused by a mechanical plugging of the capillaries 
in the lungs, which induce dyspnea and cyanosis, or to those in the 
cerebral capillaries, which cause aseptic infarction of brain tissue, with 
subsequent necrosis accompanied by convulsions and death. Schultze 
and Behan^ performed the experiment of opening dogs' bones and 
connecting them with a manometer. They obtained a negative pressure 
of about 20 mm. and believed that this negative pressure had much 
to do Avith fat embolism after fracture. Rothmann^ repeated these 
experiments, taking four middle-sized dogs. He trephined the tibia, 
inserted a threaded metal tube into the opening and lined the tube 
lumen with paraffin to avoid clotting. He was unable to demonstrate 
any negative pressure, but obtained a very slight positive pressure 
in every case. He concludes consequently that absorption on account 
of negative pressure within bones is impossible. 

LeConte and Gauss have made an interesting study of 14 cases of 
fat embolism in connection with supposed delirium tremens and pneu- 
monia following fracture.^ One of these cases. Dr. Graham's at the 
Presbyterian Hospital, was clinically diagnosed. On the second day 
the patient developed pulmonary, cerebral, and cardiac symptoms of 
fat embolism and had punctate hemorrhages in the skin. Exitus ensued 
on the fourth day. The tissues were prepared according to the method 
of Bolton and Smith.^ Fifty sections from each piece of tissue were 
examined, and five sections containing average amounts of fat were 
used to compare with thirteen from other fracture cases at the Cook 
County Hospital, which terminated fatally with delirium and high 
temperature. The amount of fat in ten fields of a section of a similar 
organ was compared with ten fields of Dr. Graham's patient, whose 
tissues were used as a standard, and the percentages of several organs 
were averaged. Quantities of fat emboli from 5 per cent, to 45 per 
cent, were found in these 13 cases. Heart, lung, kidney and liver 
sections were used in the computation. 

I quote from the report: "In all instances, the lung tissue where 

1 Muchen. med. Wchnschr., 1912, No. 52. 

2 Miinchen. med. Wchnschr., 1913, p. 1664. 

3 Tr. Chicago Pathol. Soc, April, 1915. 

* Centralbl. f. allg. Path. u. path. Anat., 1903, xiv, 620. 



COMPLICATIOXS AXD SEQUEL.E 



65 



examined contained fat emboli, which ranged in size from o/jl to 22o/i 
in diameter; also, there was active hyperemia in all, and microscopic 
hemorrhages in half. In all but one, the heart muscle contained 
vessels with fat emboli in them from Ofi to 40^1 in diameter; also, there 
was hyperemia, hemorrhages in twelve, and fatty degeneration in six. 
The kidneys from all fourteen bodies contained fat emboli from 5/x 
to SO fjL in diameter, and there was hyperemia in all, hemorrhages 
in ten, and fatty degeneration in thirteen. In the liver of six bodies, 
emboli were found, 30^ in diameter; in twelve there was engorgement 
of the vessels and fatty infiltration. In seven this accumulation of 
fat in the liver cells was marked, covering one-half to seven-eighths 
of the microscopic fields. Fat emboli were also found in the brain, 
suprarenal glands, gastric mucosa, testis, and spleen in several 
instances. Edema of the brain was diagnosed grossly in seven, and 
fat droplets were detected in the blood at the time of the postmortem 
examination in seven." 

TABLE 1.— ANATOMICAL CHANGES 







Lung. 






Heart. 






Kidney. 




Liver. 






~,~~Y^ 




, . 


a 






i 




.S 




cb 


1 






-; 
2 


■■2 § 


11 


>> 


1 




1 


"S 


1 


1 


I| 




1 


1 


Z a 


1 


1 


1 


II 




< 


1 




J5 
< 


o 


1 




MI 

m 


l^ 


K 


1- 


ll 


1 


w 


1 


100% 


10- 50 + 


+ 


10-40 


+ 


+ 




+ 


20-80 


+ 


+ 




20-30 


_ 


4- 


2 


35% 


15-35 + 


+ 


* 










10-75 


+ 


+ 


_ 


5-10 


+ 


+ 


3 


35% 


15- 60 + 


+ 


— 


+ 


+ 


— 


— 


5-35 


+ 


+ 


+ 


30-50 


+ 




4 


35%. 


15- 60 i + 


+ 


10-15 


+ 


+ 


+ 


— 


15-40 


+ 


— 


-f 


5-15 


+ 


+ 


5 


45% 


20-225 + 




20-30 


+ 


+ 




+ 


20-60 


+ 


— 


-f 




+ 




6 


40% 


10- 90 ! + 


_ 


5-15 


+ 


+ 


+ 




10-30 


+ 


+ 


-1- 


— 


+ 


+ 


7 


10% 


10- 35 ; + 


+ 


* 










5^0 


+ 




-1- 


* 






8 


15% 


10- 25 1 + 




5-20 


+ 


+ 


— 


— 


5-40 


+ 


+ 


-t- 


— 


++ 


+ 


9 


25% 


10-35 


+ 


— 


5-15 


+ 


+ 


+ 


— 


10-60 


-h 




+ 


10-15 


+-f 


.+ 


10 


25% 


* 






5-15 


+ 


+ 




+ 


10-60 


+ 


+ 


-}- 


10-15 


+-t- 


+ 


n 


20% 


5-80 


+ 


— 


10-20 


+ 


+ 


+ 


+ 


5-60 


-H 


+ 


+ 


— 


++ 


+ 


12 


10% 


20-100 


+ 


+ 


10-20 


+ 


— 




+ 


40-60 


+ 


+ 




— 


+4- 


+ 


13 


25% 


10-60 


+ 




1^35 


+ 


+ 


— 


+ 


15-55 


-f 


+ 


+ 


— 


++ 


+ 


14 


5% 


15-50 


+ 


~ 








•• 




10-45 


+ 


-F 


-f-l- 


— 


++ 


+ 



Cerebral fat emboli in 1, 3, 4, 11. (Others not examined microscopically.) 

Edema of the brain in 1, 2, 3, 5, 8, 11, 14. 

Fat droplets in the blood in 1, 6, 7, 8, 9, 11. 

Petechial hemorrhages in the skin or organs in 1, 4, 6, 7, 8, 10, 11, 12, 13. 

* Not examined. 

The SNTnptoms and diagnosis depend on the character of the 
embolism. Some authors divide fat embolism into two forms, the 
respiratory and cerebral. In the respiratory form the patient develops 
s\Tnptoms of restlessness, dyspnea or Cheyne-Stokes respiration, 
cyanosis, and vomiting within a few hours to two days after fracture 
or orthopedic operation. This condition may follow a simple fracture, 
such as a fracture of })oth bones of the leg, in an apparently healthy man. 
liales appear in the chest, a blood-stained, frothy mucus comes from the 
mouth, anrl there is fever. There is a quick progressive course with 
unconsciousness and fatal termination. The cerebral form may come 
on during the course of orthopedic manipulation, and the patient may 



66 



PATHOLOGY OF FRACTURE 



never come out of the anesthetic. Gaugele^ believes that many of 
these deaths are ' attributed to the anesthesia when they are really 
fat embolism of the cerebral type. The cerebral form may also come 
on soon after bone reduction or fracture. There are great restlessness, 
muscular twitchings, convulsions, and paralysis. A rise in tem- 
perature to 102° has been observed. Nearly all cases show marked 
dyspnea. The clinical table of the cases investigated by LeConte 
and Gauss follows. Some cases undoubtedly recover spontaneously; 



TABLE 2.— CLINICAL OBSERVATIONS. 























Symptoms. 










i 










Temperature. 
















































^ 






1 










Cerebral. 






Respiratory. 


Cardiao. 


1 









































































M 


T3 




















£ 








s 




. 




£ 






. 














^ 








J 


6 


1 


1 
1 


1 




^ 


1 


1 


1 




i 






a 


J 


■i 




5 


1 


1 


6 


1 


1 


1 


1 


1 


1 


c3 




M 




1 


1 


1 


i 
& 


1 


1 


M.35 


4 


Tib. fib. 


97.8 


106.2 


+ 






+ 


+ 


+ 


64 


C-S 


+ 


+ 


164 


+ 


2 


M. 64 


5 


Humerus 


98.0 


105.4 


+ 


— 


_ 


+ 


+ 




60 


A-H 


+ 




120 


+ 


3 


M.52 


5 


Pelvis 


98.8 


105.0 


+ 


+ 


+ 


+ 


+ 


— 


44 


Co 


+ 


+ 


130 


+ 


4 


M.59 


3 


Hiunerus 


? 


? 


+ 


+ 


+ 




+ 


_ 


? 


A-H 


+ 




142 




5 


M.42 


6 


Tib. fib. 


97.0 


103.0 


+ 


+ 


+ 


+ 


+ 


— 


40 




+ 


— 


150 


+ 


6 


M.52 


3 


Humerus 


98.0 


104.2 


+ 


+ 






+ 


— 


30 




+ 


— 


128 


+ 


7 


M.45 


5 


Femur 


98.4 


107.4 


+ 


+ 


+ 


+ 


+ 


_ 


42 


A-H 


+ 


+ 


140 


+ 


8 


M.51 


6 


Tib. fib. 


98.0 


105.6 


+ 


+ 


+ 


+ 


+ 


+ 


68 


A-H 


+ 




120 


+ 


9 


M.58 


14 


Femur 


98.0 


104.0 


+ 


+ 




+ 


+ 


+ 


60 


Co 


+ 


_ 


136 


+ 


10 


M. 62 


2 


Femur 


101.0 


106.0 


+ 


+ 


+ 


+ 


+ 


+ 


72 




+ 


+ 


134 


+ 


11 


M. 56 


6 


Tib. fib. 


98.0 


106.0 


+ 


+ 


+ 


+ 


+ 




60 


c-s 


+ 




156 


+ 


12 


F. 35 


7 


Tib. fib. 


98.6 


105.2 


+ 


+ 


+ 


_ 


+ 


— 


34 




+ 


— 


140 




13 


M.39 


5 


Calcaneus 


99.6 


108.2 


+ 


+ 


+ 


+ 


+ 


— 


60 




+ 


— 


140 


+ 


14 


F. 90 


17 


Femur 


96.9 


101.4 


+ 


4- 


+ 


+ 


+ 


+ 


48 




+ 


~ 


112 


+ 



Diagnosis of delirium tremens in 4, 6, 8, 12. 
Diagnosis of delirium tremens and lobar pneumonia in 7, 10. 
Diagnosis of delirium tremens and hypostatic pneumonia in 9, 11 . 
C-S = Cheyne-Stokes, A-H = air hunger, Co = cough . 

others are considered to be in a condition of delirium tremens, or to 
be suffering from embolism of a septic character. Pure pulmonary 
symptoms are rare, and probably in accordance with LeConte's 
findings the fat embolism is the cause of all symptoms and death. 
In only 1 of the 14 cases was there found any evidence of pneumonia. 
That was a slight bronchopneumonia. As prophylactic treatment, 
reduction by rough manipulations should be avoided, or an intravenous 
injection of normal salt solution may be given immediately after the 
manipulations. After the onset of symptoms the fracture site must 
be immobilized thoroughly to prevent motion of fragments, and heart 
stimulants and strychnine are given hypodermically. The diagnosis 
is often confused with shock, hemorrhage, and postansesthetic, pul- 
monary edema. Cotton gives Dennis's rule as a means of differentia- 
tion. Shock three hours, fat embolism three days, pulmonary 
embolism three weeks. In the Cook County Hospital in the series of 

1 Ztschr. f. orthop. Chir., 1914, xxxiv. Heft 1-2. 



COMPLICATIONS AND SEQUELS 67 

10,702 fractures fat embolism was diagnosed four times clinically. 
LeConte and Gauss call attention to the medicolegal importance of 
fat embolism and the difficulty that exists in civil and criminal courts 
of proving that death was not caused solely by delirium tremens. 

3. Delirium Tremens. — In city hospitals, delirium tremens follows 
traumata of all kinds, particularly fracture, which confines the patient 
to bed and takes away the customary amount of alcohol. In 10,702 
cases of fracture this complication was present 179 times. Some 
attacks lead to a fatal ending. If the patient is very unruly he may 
be strapped and the injured limb protected by a suitable cast. Fat 
embolism must be differentiated. There is a history of alcoholic habit 
with sudden deprivation of the alcohol. After an onset characterized 
by nervousness and restlessness, hand tremor, loss of appetite and 
sleeplessness, the condition passes into a delirium of muttering type, 
not often very violent. I saw some years ago, following an open frac- 
ture of the forearm, one case of tetanus with onset on the eighth day. 
The condition simulated an alcoholic delirium, because the twitching 
and muscle spasms of the arms with general nervousness were the 
most prominent symptoms. Trismus did not appear until much 
later. Known alcoholics should not be deprived of their drink after 
fracture. The amount taken can be gradually cut off. The bowels 
should be opened by a cathartic and as much diet given as the patient 
will take. After the onset the fractured limb is protected with extra 
dressings, and the usual treatment of sedatives, ergot, etc., is insti- 
tuted to induce sleep and quiet. 

4. Tetanus. — Tetanus is unknown after closed fracture. Open 
fracture of any bone is liable to this infection, if street dirt is carried 
into the wound. Open fractures in steel mills or factories where the 
dust and dirt are reasonably sterile do not often give tetanic infections 
Of the 10,702 fracture cases reviewed 3 had tetanus. Prophylactic 
treatment consists in ample drainage of the Avound with a cutting 
away of crushed and soiled edges. Immediate injection of 1500 
units of antitoxin is also indicated when there is any suspicion of the 
infection. When the disease is once inaugurated the treatment con- 
sists in intraspinal and intravenous injection of large amounts of 
antitoxin, according to the method worked out by Irons at the Cook 
County Hospital. 

5. Shock and Death. — Shock and death are the most important 
complications. In the series of 10,702 cases, there Avere 9768 closed 
fractures. 749 of these resulted in death; 126 resulted in shock, 
which became so pronounced that treatment was primarily directed 
to it. These cases recovered. There were 379 open fractures in the 
series, 34 of which resulted fatally and 1 had serious shock without 
death. Many factors such as age, the patient's general health, other 
injuries, hemorrhage, and other complications must })e considered in 
the sifting of the total figures. 

6. Genrral Sepsis. — General sejjsis occin*s in both ojx'n and closed 
fractures, which have a gangrene of the tissues with infection about 



68 PATHOLOGY OF FRACTURE 

the fracture site. The source of infection is probably the gas bacillus 
or the organism of a malignant gangrene. Locally the tissues become 
necrotic and foul-smelling and slough. There is little discharge of 
pus, but the wound oozes a watery, bloody discharge. Emphysema 
from the bacteriological production of gas is often seen. 

Treatment is early amputation. The most copious drainage fails to 
afford relief, and as the symptoms of general sepsis from absorption 
begin to appear inside of forty-eight hours amputation may not be 
successful. There is high fever, restlessness, and delirium with a fast 
and failing pulse. If the shock of amputation is added to this con- 
dition, the prognosis is very bad. Patients in good health may sur- 
vive, others hold out ten or twelve days, and those of alcoholic habit 
or in poor general condition die within the first week after accident. 

Late General Complication. — 1. Postural and Weight-hearing Changes. 
— Lower limb fractures which result in malunion or union which does 
not perfectly restore the weight-bearing axis, lead to late general com- 
plications which involve the gait and posture. If there is lateral or 
anteroposterior deviation of the bone axis, there results an erroneous 
deflection of the body weight. There is cross strain exerted at the 
fracture site and strain on the near-by joints. Shortening of the 
affected limb may also be present, and when function is resumed the 
patient walks with a dip toward the affected side. This causes pelvis 
tipping and lateral curvature of the spine. Slight degrees of malunion 
are often thus compensated, and the bone itself takes on a corrective 
growth of realignment in accordance with the idea expressed in Wolff's 
law. The same statement applies to upper extremity fractures, inas- 
much as the function of the limb is disturbed. These complications 
must be guarded against by the obtaining of perfect reductions and 
the employment of correcting splints and supports after use of the part 
is started. 

2. Neurasthenical Conditions. — Neurasthenical conditions are com- 
monly seen in both hospital and private practice following fracture. 
These conditions are sometimes found in those who seek damages for 
accidents or have claims under compensation acts. Sometimes patients 
get into a marked condition of mental depression; they have no 
desire to aid themselves or return to occupation, and they drift into 
hospitalism. Others, and many men are among them, will nurse an 
unimportant fracture for months or years, ascertaining all sorts of 
remote complications in order to obtain damages or awards under 
compensation laws. I have recently been interested in a case of 
fractured clavicle with no complications, following which the injured 
man has done no real work for five years, although the result is above 
the average. Pecuniary settlement often sets these people with 
simulated neurasthenical conditions right, and the mental recovery 
follows very quickly. 

Local Complications. — Early Local Complications. — Local complica- 
tions are in reality local conditions affecting tissues other than the 
bone at a fracture site. Many cases escape untow^ard consequences,. 



COMPLICATIONS AND SEQUELS 69 

and we are likely to overlook the local pathology of the soft parts 
except in those cases Avhere its exaggeration attracts attention. The 
mnscles and fascial sheaths lie nearest the bone and are injnred hy the 
tranma causing the fracture, by penetration of bone fragments or 
pressure from within the limb through hemorrhage and extravasation. 
The muscle may be torn completely with much hemorrhage. Fascia 
is tougher and yields less, but is frequently ruptm-ed. The repair 
is by connective tissue which may become adherent to surrounding 
parts. (See Late Local Complications.) There is always swelling, sore- 
ness, and edema. Hemorrhage may burrow for a long distance beneath 
intact fascial sheaths and cause pressure complication. 

Volkmann's ischemic contraction is the term applied to a type of 
contraction of the muscles and the changes in the soft parts distal 
to the point of fracture. 

Causes. — ^^'olkmann's original description in 1875 attributed the 
contraction to tight bandaging, which led to an ischemia of the muscles 
from pressure. There was no primary nerve pressure injury. We 
believe now that the p;ressure may come not only from tight bandag- 
ing, splints, or casts, but also from pressure within the extremity 
caused by the extravasation of blood beneath resisting fascial envelopes. 
There are cases on record following fracture in which no splint or 
bandage of any kind was applied. Murphy,^ Collinson,^ and Jones^ 
have seen cases. Bardenheuer^ states that 8 per cent, of the cases 
follow fractures to which no dressing or attempts at reduction have 
been applied. Jones reported having treated 24 cases up to 1908. 
19 of these were associated with fracture, while 6 cases had not sus- 
tained fracture. Of these 6, 2 were arms which had been crushed 
by wheels, 1 had been subjected to pad pressure on the forearm for 
twenty-four hours to stop bleeding from the palmar arch, and 1 was 
a child's arm from which the elastic tourniquet had not been removed 
after an operation for webbed fingers. A few authors have attributed 
the contraction to primary nerve involvement, or a localized ischemia 
involving certain bloodvessels or muscle groups. Exposure to extreme 
cold has also been considered a cause. 

Pathology of Volkmann's Contraction. — Volkmann and Bardenheuer 
were of the opinion that the condition was caused by a necrobiosis 
of the muscle cells caused by interference with circulation of blood 
in the part. Bardenheuer thought that the muscle cells were poisoned 
by the metabolic products in the unchanged blood of the part and 
the necrobiosis was really death from auto-intoxication. The more 
recent investigators believe that the process is a pressure ischemic 
myositis caused by the pressure of hemorrhage within the tissues, 
which is often aided by external compressing bandages or casts. 
There develops a myositis which leads to contracture of the muscle 
as a whole. The muscle body is atrophied and becomes a grayish 

1 Jour. Am. Med. Assn., Iviii, No. 15, 1249. 

- IV)id., p. 12.55. ■' Am. Jour. Orthop. Surp;., 1008. 

* Deutsch. Ztschr. f. Chir., 1910, cviii, 44. 



70 PATHOLOGY OF FRACTURE 

color, like ;i mass ol' connective tissue with scant blood supply. Frac- 
tures about the elbow are the most frccpient cause. Thirteen of the 
19 eases Jones rei)orted as coimeeted with fracture had malunion, 
and o had excess callus and good alignment. There are a few cases 
occurring after fractures about the knee. The damage to the muscle 
cells is done within the first seventy hours, but the muscular contrac- 
tion and flexion of the fingers come on later. The retraction of the 
fingers may not start to manifest itself until three or four weeks, when 
the cast or dressing is removed. In some cases in which no bandage 
or splint was u^ed, the contraction has started on the third or fourth 
day after injury. In three months the fingers become fixed in their 
flexed position, and further changes are not caused by muscle shorten- 
ing, but are probably the result of complete exhaustion of the exten- 
sor muscles, and an increase in the length of the bones. The nerves 
are rarely involved, and it is believed that nerve injury is not essential 
to the muscle contracture. The reported cases of cure following 
operation or Jones's extension method corroborate the supposition 
that the nerves remain intact in most cases. Nerve injury may be 
caused by trauma or by callus pressure, but rarely from pressure of 
the infiltration or the muscle contraction. 

Symftoms. — The early evidence of the pressure ischemia in the muscles 
is swelling and stiffening in the hand and fingers, accompanied in some 
instances by cyanosis and coldness. There is always continuous and 
intense pain. The patient complains, and the splint may be removed. 
When it is not, the swelling and cyanosis in the hand and forearm 
increase, and the pain gradually subsides. No attention may be paid 
to the pain which is considered a necessary symptom of the fracture, 
but the changes in the muscle occur very rapidly and at the first 
evidence of swelling and edema with cyanosis the dressing should be 
loosened. Later symptoms consist in the flexion deformity of the 
fingers and hand. There is great atrophy, the hand and fingers are 
in flexion. The extremity is cold and the skin glazed and blue. There 
are contractions of the capsular ligaments of the joints involved. The 
fingers are flexed into the palm, and when an effort is made to extend 
the wrist the finger-nails bite into the palm. If the wrist is further 
flexed, the fingers may be extended a little, but in cases of long stand- 
ing the capsular ligament about the joints become stiffened and con- 
tracted. The elbow is flexed, and the forearm muscles are atrophied 
and feel like a hard mass moulded together. If there has been con- 
comitant nerve injury, there will be an electrical reaction of degenera- 
tion in the muscles. 

Treatment. — Prophylactic treatment consists in avoidance of con- 
stricting bandages or splints about fractures of any kind, particularly 
those involving the lower end of the humerus and the forearm. Splints 
should not be applied to force a reduction of a fracture. The fracture 
must first be reduced and external splinting must serve merely as a 
mechanical fixation in the position gained. It is also wise to allow 
the first traumatic swelling to have full freedom. No tight bandages 



COMPLICATIONS AXD SEQUEL.^: 71 

should be applied, and the limb must be put at rest in a comfortable 
position. This rule also means that fresh fractures about the elbow 
region should not be treated b\' an inuiiediate position of extreme 
flexion. When the arm appears cold, swollen, and cyanotic, and per- 
sists so in spite of removal of all dressing, the rigid fascia on the ulnar 
side of the forearm should be split for several inches subcutaneously 
to relieve pressure of the hemorrhage within the tissues. At the elbow 
the antecubital region may also be opened subcutaneously. These 
operations can be performed through a small skin opening with 
a tenotome. Reduction and permanent dressing of the arm are 
postponed until swelling has subsided, that is, for a week or ten 
days. 

Treatment is non-operative and operative. The non-operative aims 
to produce and maintain extension of the fingers and restore forearm 
function by massage and electricity. This is seldom successful in any 
degree. Jones's method, described in 1908,Ms as follows: fine zinc or 
iron strips are cut which fit the patient's extended fingers. While 
an assistant flexes the wrist, the fingers relax enough to permit each 
finger to be splinted by one of the metal strips, which are bound on. 
The patient attempts to extend the hand, and in a few days a splint 
is applied over the first splints and extending from finger tips to wrist, 
with some extension gained gradually. Further extension efforts are 
made by the patient, and later splints are applied as high as the 
elbow, so that by degrees the wrist becomes fully extended. When 
the hand becomes hyperextended, its circulation improves and the 
difterent tissues take on a more normal appearance. Jones thinks 
that every structure is stretched in the order of its tension, and that 
the method should be preferred to open operation. 

Operative methods have been devised and used to shorten the fore- 
arm bones by removing a section of each and wiring or plating the 
fragments together. W'hen this is done aseptically wdth bony union 
the results are good. Efforts to cut the muscles subcutaneously 
produce no lasting benefit, because cicatricial contraction follows with 
greater shortening than ever. The best open operation is a tenoplasty 
to lengthen all the flexor tendons above the wrist. Murphy gives the 
principles of this treatment as follows: There is a correction of the 
tendon deformity by true elongation, not mere division. The muscles 
groups must be balanced so that there is no tendency to subsequent 
contraction. Sufficient transverse division of the joint capsule at the 
wrist and the forearm fascia must be made at the operation to permit 
full motion of the hand and wrist to a position of hyperextension, 
where it is maintained during the healing. 

The adjacent tendons are not divided on the same plane, and as each 
one is divided it is sewn, but the sutures are clamped and not tied 
until all tendons are free. Elongation must be sufficient to permit 
full extension of the wrist. The after-treatment consists in gentle 

' Loc. cit. 



72 PATHOLOGY OF FRACTURE 

massage and active attempts at use by the patient, satisfactory final 
results following in most cases after many months. 

Nerpe Complications.— ^arly nerve complications are rare. In arm 
and leg fractures an effort should l>e made to ascertain at the first 
examination whether the important nerves have been injured. In 
fractures of the spine, or clavicle, or about the shoulder region, the 
branches of the brachial plexus may suffer injury or be totally avulsed 
from the spinal foramina. The commonest nerve injury is that of the 
musculospiral nerve in fractures of the humerus — which see. About 
the elbow^ the ulnar and median nerves may be injured, and near the 
knee the external peroneal nerve may likewise be damaged. 

Bloodvessels. — In closed fracture arteries and veins are seldom seri- 
oush^ injured. Their shape protects them, and if they are torn across 
the retention of the blood within the tissues prevents extensive hemor- 
rhage. Vessel coats may be lacerated and weakened without complete 
rupture at the time of fracture. Subsequent manipulation or move- 
ment of the part may complete the tear, and a secondary hemorrhage 
wdll result. Traumatic aneurism may also develop after a partial 
injury and slowly proceed during the course of the bone repair. Tear- 
ing of the lymphatic vessels and their closure may lead to prolonged 
edema in a limb. 

A few fractures are commonly associated with bloodvessel destruc- 
tion and hemorrhage. Rupture of the middle meningeal artery in 
skull fractures is one of these. Fractures and dislocations of the head 
and neck of the humerus are likely to wound the axillary vessels, and 
the subclavian in clavicular fractures, the popliteal in lower femoral 
fractures, and the tibial or nutrient arteries in the leg may also be 
involved. Open fractures, especially those caused by direct violence, 
cause bloodvessel injury. Laceration of muscle bellies opens a great 
number of small bleeding-poiiUts, and frequently vessels of consider- 
able size are ruptured. The character of crushing injuries protects 
against severe hemorrhage in many cases, because the bloodvessels 
are compressed or retracted within the muscle masses and the intima 
rolls in to close the lumen. I have seen several crushing leg and arm 
injuries with almost total severance, which bled but little. Less severe 
injuries which have an open wound may cause bleeding from one 
point which is exhausting. There has not been enough trauma to 
close the vessel. Bleeding is more serious from torn veins than from 
arteries as a rule, and may continue for hours. Legs with varicose 
veins are dangerous in this connection. 

The symptoms of hemorrhage within a limb are pain and increased 
local sw^elling, which usually becomes pulsating and interferes with 
circulation distal to the fracture site. Compression at this point by 
bandage is not indicated. Rest, elevation, and the application of 
cold may alleviate the trouble, but if the condition persists and 
nutrition of the limb is threatened, open operation to stop the hemor- 
rhage and repair the fracture is indicated. Rupture of a vein causes 
symptoms appearing more slowly and is difficult to recognize. 



COMPLICATIONS AND SEQUELS 73 

Gangrene is a rare early complication. The tissues locally may 
necrose from pressure and interrupted blood supply. Local patches of 
tissues and skin become blackened and slough even in closed fracture; 
ulceration may proceed, which residts in a late opening of the fracture 
to the air. The prognosis of superficial patches of dry gangrene is 
good. Granulation beneath accompanies the separation on the 
surface, and by the time the patch is freed the area beneath it is on 
a road to recovery. Secondary infection beneath a patch spreads 
locally into the fascial and muscle planes and causes a foul-smelling, 
watery discharge which clears up under sufficient drainage. 

Gangrene of a whole or distal portion of an extremity is rare in 
closed fracture. It may occur in elderly patients caused by rupture of 
the important artery, or by pressure from hemorrhage within a limb 
on aU of its blood supply. Incisions into the skin and fascia for 
drainage to relieve this pressure are practically never necessary. Some 
of the most extensive and prolonged infections of bone and soft parts 
I have ever seen have followed incision to relieve pressure which 
appeared to threaten distal circulation. Elevation, hot or cold applica- 
tions, massage, and other external maneuvers must be employed, 
or the fracture must be opened under the rigid asepsis of operative 
technique and tightly closed after reduction. 

The inception of extremity gangrene is manifested by a change of 
color of the skin and the appearance of blebs, which are often bloody 
and dark stained. The limb becomes cold, and sensation decreases 
in it. All constricting bandages or adhesive dressing should be removed 
at once and heat applied. In the 10,702 fracture cases reviewed at 
the Cook County Hospital, there were but 5 cases of gangrene in 
closed fracture. 

Thrombosis originating from trauma or infection at a fracture site 
may extend the length of a limb and result in moist gangrene where 
a vein above is involved or a late dry. gangrene, when the arteries are 
concerned. Embolism may be an early complication if manipulation 
dislodges a portion of a thrombus. 

The treatment of open fracture and the indications for amputation 
for threatened or established gangrene are considered in the chapter 
on Treatment. Bloodvessel anastomoses and plastic repair in a fresh 
fracture site are practically never a success. 

Late Local Complications. — 1. Callus Complications. — (a) Exces- 
sive and Painful Callus. — Excessive callus is the result of wide displace- 
ment of fragments, irritation of motion, the presence of small necrotic 
fragments and a hyperactivity of the osteogenetic cells peculiar to 
some individuals. Fragments which are widely separated need a 
large callus to cement their union. Small fragments which become 
necrotic and lie in the path of the main callus repair are overgrown 
by the new bone formation and remain as an irritation until they 
have been absorbed or revascularized and made over into new bone. 
This process is similar to the absorption of the necrotic area on the 
edge of the fracture plane, which precedes repair in all complete frac- 



74 



PATHOLOGY OF FRACTURE 



tuiTs. It is not like sequestrum formation following infection, in 
which the most (himaged i)art of the bone is exfoliated after its death. 
Some jHM-sons tend to develoj) a large callus for no explicable reason. 
Motions of ijremature use, or massage and passixe motion forced on 
fractures near joints, are likely to lead to excessive callus. This 
callus may not appear large to external examination, but it may lie 
at just such a point that it interferes seriously with joint motion, 
restricting it so that there is functional loss. Excessive callus is also 
found in open fractures which have become infected. Large masses 
of bone with sinuses and granulating suppurative patches may sur- 
round a fracture site. Parosteal bone formation, which may be 
called excessive or unnecessary callus, is considered under the late 
complications involving muscle and fascia. 

Excessive callus frequently diminishes in size in six to twelve months, 
as use of the part is insisted upon. The enlarged bone shrinks down 
to conform with the physiological demands. In some cases, however, 
with malunion the excessive callus persists and remains to interfere 
permanently with circulation or to cause pressure effects on the 
nerves and skin. In these cases the callus is removed by operation. 
External applications, massage, and the Roentgen rays have little 
power to promote absorption. The mass can be chiseled off and the 
contour of the bone restored to normal. Near joints, if the articular 
surface is encroached upon, a modified arthroplasty must be done. 
After the excessive bone is removed, the denuded surfaces are covered 
with pedunculated flaps of fat or fascia from nearby areas. In this 
way, further regeneration of bone is provided against and a movable 
joint is insured. The elbow, shoulder, and hip are all adapted to this 
type of operation, and the results are satisfactory. 

Painful callus is often an excessive callus. A large mass may press 
on nerve trunks, it may include some terminal nerve filaments in its 
body, or by attachment to muscles, tendons, and interference with 
joint action, it may produce pain. On the other hand, painful callus 
may not be of unusual size. When the pain begins early in the healing 
of the fracture, it is probably on account of the inclusion or com- 
pression of a nerve, unless there has been an open fracture with 
infection. The pain is usually continuous and after several weeks 
subsides, as the nerve is obliterated by the pressure. Neuritis caused 
by systemic conditions or trauma received at the time of fracture 
must be differentiated before operation is advised for relief. Attention 
must be directed to focal infections in all parts of the body to rule 
out metastatic infections of nerve trunks. The teeth, cranial sinuses, 
urethra, prostate, gall-bladder, appendix and bowel must be inves- 
tigated in regard to infectious condition. If local applications are 
valueless to relieve a bruised nerve, and infectious neuritis is ruled 
out, operation on the callus must be undertaken to alleviate the pain. 
After excessive use or weather changes, callus may be sensitive for 
many months or years succeeding fracture. The knowledge we obtain 
of the arthritides, however, seems to indicate that many of these 



COMPLICATIONS AND SEQUELS 75 

prolonged and painful conditions in the callus are comparable to the 
low-grade infections which cause the slow progressi\'e and painful 
changes in osteo-arthritis. 

Painful callus originating late in the healing process is nearly always 
caused by infection and osteomyelitis. Most of these cases have 
followed open fracture and operati^'e repair of closed fractures. The 
pain may not be noticeable for some weeks. x\fter the patient begins 
to walk or to use the limb it becomes evident and is worse at night. 
Eventually there is an appreciable tenderness to tapping over the 
bone. There may be some swelling, and sinuses will appear through 
the skin. Painful callus or pain in a fracture site arising late should 
always be subjected to roentgenogram. Small areas of necrotic and 
infected bone are detected by their dark shadows. Rest in a plaster 
encasement, intermittent periods of hyperemia by means of a con- 
strictor, and general hygienic measures may bring about absorption 
of these spots with relief of pain. When they persist, open operation 
with curetting and drainage is indicated. 

(b) Weak Callus. — Weak callus becomes apparent after a normal 
course of bone repair. It is not comparable to delayed union or' 
non-union, because both clinical and Roentgen-ray examination may 
show a satisfactory osseous consolidation about the fragments. Callus 
may appear normal and yet become weak and inefficient under three 
conditions : 

1. Premature use of fractured part and its subjection to great 
strain before complete calcification has taken place. 

2. A secondary weakness caused by systemic conditions. 

3. Local conditions — pressure of bandages and peculiarities of the 
type of fracture. 

Premature use of fracture- before complete consolidation causes 
irritation and leads to an increase in the callus reaction. If use is 
persisted in, movement may develop, and the callus bends to give 
under the stress. An absorptive reaction may be set up. An ordinary 
example of this type of weak callus is found in the ankle after fracture 
of the external malleolus. Patients are permitted to start walking 
without support under the foot arch in the fourth or fifth week. Bone 
union is generally present, but as the body weight is applied on the 
fresh union, the callus becomes inadequate to hold under the lateral 
strain and begins to give a little. The result is that although the 
patient was discharged after four weeks with a straight ankle and 
foot in proper weight-bearing line, he returns in four more weeks 
with a pronated painful foot, and a weak, yielding callus in the site 
of the fibular fracture. This same mechanism may cause giving in 
any fracture. (See picture of plated fracture of femur walked on 
too soon.) 

The second cause of weak callus is systemic syphilis, scurvy, lacta- 
tion, faulty calcium metabolism and general infections which lead to 
absorption of callus and its weakness. The process may be slow, and 
an angular deformity from giving of the bone results after some 



76 



PATHOLOGY OF FRACTURE 



time. In some conditions if slight trauma is added, refracture may 
occur tlu'ougli tlie original site (Fig. 18). This refracture occurs in 
some cases of internal splint fixation which are clean, especially in 
those repaired by intramedullary bone grafts. It is a question whether 
there is a systemic condition to blame or whether the absorptive 
process in the transplant has a broader local effect and weakens the 
callus so that trauma easily effects refracture. 

Local conditions at the fracture site also have influence on the callus 
strength. Fractures of the shaft of the femur in which a triangular 
piece of the heavy compacta is removed or broken off are likely to 



Site of resection 




1 



Fig. 18. — Fracture through a united resection of the knee. Note that the plane of 
fracture has not followed the old joint line which has firmly united, but has taken a 
new course as if there were one long bone from hip to ankle. 

have a weak callus. They should be granted a long period of rest 
that the callus may become thoroughly calcified and contracted so 
that the new lamellse are capable of taking on the strain of weight 
bearing. The application of tight bandages or other interference 
with free circulation and injudicious use of the muscles about the 
fracture site in a long bone may cause weakening of the callus. 

(c) Delayed Union. — (d) Non-union, — ^These two subjects are con- 
sidered together not because they are identical, but because delayed 
union sometimes merges into non-union and the terms have been 
loosely applied in practice. Delayed union means that the ordi- 



COMPLICATIONS AND SEQUEL^: 77 

nary time required for the establishment of bony union in fracture of 
a long bone is exceeded. Each fracture must be judged by a number 
of similar fractures in the corresponding bone with more or less the 
same type of displacement. After an average time for union is deter- 
mined upon, other factors then come into consideration. The patient's 
age, general condition, surroundings, and the type of dressing may 
influence the time needed for repair. The individual osteogenetic 
power also has a bearing on the rapidity. 

An example may be taken of a fracture of the shaft of a long bone. 
In the course of an average repair period the surgeon removes the 
permanent dressing to inspect the limb. He is surprised to find when 
tests are made, more or less freedom of motion at the fracture site. 
Often instead of replacing the dressing to permit a longer period of 
immobilization, he begins to worry about non-union, and the limb 
is inspected daily and all possible expedients are called into play to 
promote union. The slight motion and irritation of the fragment 
ends may be beneficial. If union does not follow very shortly the 
fracture is put into the class of non-union long before its time. Prob- 
ably e^'ery surgeon of experience has seen fractures of the shaft of the 
tibia or femur which took six months to become firmly united. Delayed 
union is a fairly frequent occurrence; fibrous union, pseudarthrosis, 
and non-union or failure of union are rare. 

Fibrous union is a term which signifies that the bond which has 
developed between two fragments is in a connective-tissue stage; that 
is, the fibrous tissue proliferation from the periosteum or surrounding 
parts predominates, and the outgrowth of bony lamellse has been 
checked or partly inliibited. This fibrous band, though strong, is not 
solid, and permits motion and causes functional loss. In the patella 
and sometimes in the femoral neck we anticipate such a union. In 
the shafts of long bones, a fibrous union, given time and aided by 
efforts to promote calcification, will often terminate after months in a 
solid, bony junction. 

Pseudarthrosis indicates the formation of a false joint between the 
connected fragment ends. This false joint has a heavy fibrous outer 
wall, which simulates a capsular ligament and a synovial-like surface 
within. Non-union or failure of union is a term which means absence 
of bony gro^vth between fragments, so that this term is the broadest 
and covers both fibrous union and pseudarthrosis, but also implies 
that the union present will never become bony if left to itself. Failure 
of union is a term which should only be applied to the exceptional 
cases which show lack of bony union of months' standing and which 
are hopelessly permanent. 

In tlie total series of 10,702 fractures reviewed at the Cook County 
Hospital, there were 123 cases of uiuniited fracture. Some of these 
cases were not trne failures of union, but re])rescnted the class of 
delayed imion, and the older history sheets do not warrant an exact 
discrimination. The proportion of non-unions after fracture probably 
is less than 0.6 per cent. The most frequent site of non-union is in the 



78 PATHOLOGY OF FRACTURE 



I 



lower third of the shaft of the humerus, if we consider long bones only. 
The next most frequent site is the lower third of the tibia; next the 
upper third of the humerus, and the lower third of the forearm, the 
upper third of the leg and finally the femur follow in order. Murphy 
in one statement,^ puts fracture of the lower third of the tibia in 
second place, and in another place^ he puts the tibia in fourth place 
on the list. Open fractures are more frequently followed by non- 
union than closed, especially those which have been treated primarily 
by internal splints. Sprain fractures, separation of small pieces near 
the articular surfaces of bone, and fractures of the femoral neck, 
are not included in this enumeration. Hawley^ reports 53 cases 
of ununited fracture in a total of 1200 cases. His cases had a dis- 
tribution different from what most authors have recorded, because 
none involved the humerus, ulna, clavicle or fibula. With the neck 
of the femur excluded no ununited fracture involved the vascular 
ends of long bones, but the sites were shaft of the tibia 22, the femur 
15, and the radius 10. 

Cause of Non-union. — General causes attributed to the patient's 
systemic condition were formerly considered of the greatest impor- 
tance. These were defective nutrition arising from tuberculosis and 
rickets, alcoholism, malignancy, pregnancy and lactation, defective 
innervation as in tabes, syphilis, and acute systemic infections. Most 
of these causes after close investigation have been laid aside; even 
alcoholism and syphilis are no longer seriously considered as primary 
causes of non-union. Hawley found non-union in only 1 out of 
8 cases of fracture caused by carcinoma of bones. (See chapter on 
Bone.) The disturbance of the calcium equilibrium has some bear- 
ing. Defective innervations and tumor formations have been put 
in the class of pathological fracture where they belong. There remains 
for consideration the various local causes. The order of their impor- 
tance is not easily established. Open fracture, and particularly 
open fracture which has been fixed by internal splints, comes first. 
(See paragraph on Pathology.) Murphy^ reports 5 cases of ununited 
fracture, all of which were originally open and 2 of which were operated 
on for the application of internal splints. Of 4 cases which I have 
seen in the shafts of long bones in the last year, 1 had been repaired 
by a Lane plate, and all were open fractures except 1 in the tibia. 
Failure of approximation of the fragment ends, either on account of 
angulation and overriding, or the interposition of muscle and fascia, 
are other causes. Interference with blood supply, particularly destruc- 
tion or thrombosis of the nutrient artery, is a much overlooked cause. 
Too perfect immobilization which results in an insufficient stimulation 
for callus production by slight movements has been advanced as 
an etiological factor. The only argument in favor of this factor is 
that some motion seems to stimulate bony consolidation in delayed 
union. Near joints we know that premature and painfully enforced 

' Clinics, i, 192. 2 if^i^., iii, no. 

' Jfjur. Am. Ortho. Assn., 1914, p. 245. ■» Clinics, i-iii. 



COMPLICATIONS AND SEQUEL.^ 79 

moA'ements cause an excessive amount of callus which interferes with 
the joint function. ^Maltreatment by the application of cold, the 
admission of infection through artificial wounds, insufficient immob- 
ilization and protection, and too early use all have a bearing on 
non-union. Some fractures after firm union will become freely movable 
later. The callus absorbs by some disturbance of the calcium dis- 
tribution, possibly influenced by systemic disease. 

PafJwlogy of Xon-uuion. — In open fracture there is more or less 
bleeding and draining away of the blood-clot which is believed to act 
as a support for the capillary outgrowi:h from the bone ends along 
which the new bone is laid down. There is also in a large percentage 
of cases some infection. This infection may be of very low grade, 
but by its toxic and lytic effect it causes destruction of the delicate 
bone projections and promotes their absorption. There is likely to 
be greater traumatization of the parts in open than in closed fracture, 
so that the preliminary layer of necrosis on the fragment ends is 
thicker. There are also small isolated bone fragments and greater 
interference with blood supply. During the slow local absorption 
under the conditions of open fracture there is tendency for a greater 
development of fibrous tissue from the periosteum and the surrounding 
soft parts, and as this fibrous tissue ages it contracts and crowds in 
between the bone ends, shutting off a possibility of early normal bone 
union. Cysts or joint-like spaces may develop in this fibrous tissue 
stimulated by the friction of use before bone is formed. In some 
cases small collections of blood are thus encapsulated between frag- 
ments and through metaplasia of the cells lining the cavity containing 
the blood, a synovial-like surface develops and pseudarthrosis results. 
In open fractures of the humerus internal splints applied on the bone 
aggravate and prolong circulatory interference and favor infection. 
They are consequently a secondary cause of much consequence in 
failure of union. 

Accurate approximation and anatomical reposition of fragments 
prevent failure of union, Vjecause they lessen the distance which the 
capillary growth and the bone deposition must cover. Overriding, 
angulation, interposition of muscle and fascia, which increase the 
difficulty of the bone regeneration across a space, favor the occurrence 
of non-unions. Clinically we find failure of union of two types, one 
which presents a fair approximation of fragments with a fibrous band 
between them, and a second type with either overriding or separation, 
which is true pseudarthrosis. In the first type, which is the commoner, 
the fragments m^y not be worn off or appear abnormal, except that 
the ossification process between them has stopped in its course at 
some point. There may be exostoses from the fragment ends sticking 
out into the fi})rous tissue, or there may be soft callus along part of 
the fibrous bridge, l)ut tlie repair is atypical. When a gap exists 
between fragnients jind pseudarthrosis is present, the fragment ends 
are generally eburnated and well i-onnded, the niednllarx' ])lng being 
as hard as compact bone. 



so PATHOLOGY OF FRACTURE 

The character of the blood supply is difficult to demonstrate in 
ununited fracture. The influence of a lack of good supply which may 
have existed at the time of fracture cannot be demonstrated after 
the condition of non-union exists. Studies of osteogenesis, however, 
show the character of capillary regeneration in the formation of new 
bone, and the observation of frequent non-union of the tibia alone in 
f ractiu'e of both bones of the leg calls attention to the question of 
interference with blood supply. The two bones lie side by sidjC, sub- 
ject to similar s^^stemic conditions. One unites, the other does not. 
If the local conditions of tissue laceration and type of fracture are 
the same, as they must be in most cases, one must search for vascular 
difTerence to explain the non-union. One fragment of the tibia may be 
cut off from a vascular supply, and the laycx' of necrotic bone on the 
fragment surface is not promptly absorbed and revascularized. The 
local increase of regenerative powers is diminished, there is not enough 
force to the bone-growing surface, and this is overcome by connective- 
tissue regeneration from the periosteum or from surrounding tissues 
which have better and independent blood supply. The periosteuni 
acts as a protector to bone capillaries and holds back the flood of 
young connective-tissue cells from the soft parts. When the peri- 
osteum is completely torn apart, these cells are free to wander in, and 
their growth crowds back the slower bone. 

The effect of nerve influences of a trophic character is vaguely 
understood. It is clinically established thfat motor and sensory par- 
alysis of a limb has little effect on the healing of a fractured bone in it, 
but trophic lesions do in some cases cause non-union. 

Symptoms of non-union follow the line of those of delayed union, 
the latter merging into failure of union. There is abnormal motility 
at the fracture site after the surgeon expects a bony healing in a normal 
course of events. This period cannot be stated in specific time for 
any bone, and all cases which have a fair reduction and seem to offer 
no local evidence of interposition of muscle and fascia or necrotic bone 
fragments and which lack infection, should be considered as delayed 
union. Their treatment should continue as originally planned until 
one is positive that failure of union is present. 

When the conditions of reduction are unfavorable on account of 
overriding and displacement, or when infection and other local con- 
ditions influence the progress of the union, agreement on the presence 
of non-union is easier to obtain. Young callus we know casts no 
shadow in the roentgenogram. If a fracture which has gone twice 
or three times the normal period required for union shows a clear 
line in the roentgenogram, excellent evidence is furnished of failure 
of callus formation. The mobility is the best evidence of all, because 
pain, swelling and crepitus may be entirely absent. The amount of 
motion varies. It is often difficult to demonstrate, particularly in the 
tibia, when the fibula helps maintain the rigidity of the leg. Func- 
tional disturbance does not vary directly with the mobility. Patients 
with an easily demonstrated point of mobility may be able to use a 



COMPLICATIONS AND SEQUEL.^ 



81 



leg or forearm quite satisfactorily and complain against further treat- 
ment when the non-union is discovered. Ultimately this function 
would be far below normal if deformity followed use and muscular 
pull (Figs. 19, 20, and 21). Some ununited fractures are painful. 
This type is often accompanied by an excess of callus production, 
and mechanical circulatory interference with constant pain after use 
is the symptom which leads to recognition of the condition. Sepsis 
must be differentiated, as must also tumor formation. If the humerus 
and femur are involved, especially the latter, function is much inter- 
fered with. (See illustrative cases in chapters on Fractures of the 




Fig. 19. — Ununited fracture of humerus, nineteen years old. When he attempts to 
raise arm, upper fragment of humerus is pulled up normally, but on account of false joint 
in arm at site of non-union, the lower portion hangs down and cannot be elevated. Hand 
and forearm have good power and he can carry weights as shown. 

Humerus and Femur.) In non-union of leg fracture the patient is 
often able to walk with a cane if the leg is strengthened by a metal 
or plaster splint. 

Treatment of Xo7i-union. — Mr. Robert Jones^ says that ununited 
fracture is often the result of surgical impatience. There would be 
fewer cases if there were less operative work undertaken to apply 
internal splints to open fracture. Also, as previously stated, instances 
of delayed union should be given persistent attention directed along 



Brit. Med. Jour., December 7, 1912. 



82 



PATHOLOGY OF FRACTURE 



the line of the treatment originally planned until hope for any bony 
union is lost. Too frequent manipulation and inspections are harmful. 

The chapter on Treatment deals with this subject, and it is simply 
necessary to recall the general line of treatment to be adopted with 
brief review of the many expedients which have been tried. 

First of all it is unwise to use internal splints on open fracture. If 
there is infection in open fracture, that fact necessitates primary 




Fig. 20 




Fig. 21 

Figs. 20 and 21. — Ununited fracture of humerus, nineteen years old. Note that he can 
make fist and completely extend the fingers and hand. He has to support the heavy 
muscular forearm at elbow in holding the arm in an extended position for this picture. 
No evidence of injury to any nerve of brachial plexus. 



attention in the way of drainage, and though the limb is held in a 
suitable dressing to prevent deformity, the bone union is looked upon 
as secondary. Non-union existing in bones which have been fixed 
by wires, screws, nails, plates or other internal splints, must be studied 
by roentgenogram, and in most cases they pass into the operative 
class at once for removal of foreign bodies or the drainage of infection. 
Constitutional diseases are treated, if they are considered at fault. 



COMPLICATIONS AND SEQUELS 83 

Antispecific treatment in syphilis is indicated until enough clinical 
evidence is fiu-nished to show the effect of syphilis on bone repair. 
Nourishing diet, hematinic tonics, and outdoor life must be used for 
stimulating general effects. I have never seen a case in which the 
use of glandular extracts such as thyroid had any effect. (See Local 
Non-operative Treatment.) 

It is my practice to put every case of delayed union back into its 
original line of treatment, usually a plaster dressing of some character. 
In the leg a fahly heavy plaster encasement is used, and the patient 
is permitted to use crutches. Sometimes slight use of the foot is 
encouraged in order that irritative stimulation may be afforded to 
the bone. The value of this stimulation lies not so much in the local 
irritation at the fracture site as in the strain put on the longitudinal 
axis of the hone. This calls for a deposition of calcified material in 
accordance with Wolff's law, because the bone is responding to physio- 
logical demands. 

^Massage and local hyperemia by Bier's method of constriction or 
by baking are also used. The Thomas method of damming and 
percussion is performed by a heavy mallet, the ends of which are 
padded; the application of broad rubber tubes a few inches above 
and below the site of non-union supplies the hyperemia. Daily beat- 
ing is performed with a splint applied in the intervals. This leads to 
many cures. Local treatment is also furnished by cupping or by the 
application of a plaster encasement in which a window is cut over 
the fracture site.^ 

There are other therapeutic measures applied by hypodermic 
injection at the fracture site. Tincture of iodine, adrenaline chloride 
solution, 1 to 1000, blood serum or the patient's whole blood,^ and 
various emulsions of bone-marrow or phosphates have been advocated. 
Osmic acid has been used.^ ]\Iarcozzi^ proposes a filling for bone 
cavities something like the ]Mosetig-]Moorhoff bone plug. He leaves 
out iodoform and mixes equal parts of calcium carbonate and phos- 
phate sterilized by heat. These are shoveled into the cleansed bone 
cavity. An emulsion of these salts in sterile liquid vaseline has been 
used in non-union. Bone filings have been advocated by -Farr.^ 
and Kaufl9er.^ Bone obtained from the morgue is dried, ground to 
a powder, mixed with petrolatum, and sterilized by being boiled in 
a flask for two hours. A small syringe with a long needle is used 
to inject the emulsion around the fractm-e site of fresh or ununited 
cases. As the bone cells in the emulsion are dead, they do not act 
as a centre of osteogenesis, but the whole may act as a medium of 
transmission for the outgrowing capillaries. 

' Sprengel, Arch. f. klin. Chir.. Bd. cv, Heft III, 599. 

2 Lyle, Ann. Surg., 1913, p. 284; Bier., Med. Klin., 1905. 

3 Onorato, Gaz. Med. Lombarda, 1913, p. 9. 
** Riforma mod., Naples, xxx. 

^ Journal-Lancet, xxxiii, 432. 

6 New York Med. Jour., November 21, 1914, p. 1013. 



84 PATHOLOGY OF FRACTURE 

Operative Treatment. — The simplest measure is drilling. Through 
small skill openings drill holes, running diagonally into the shaft, are 
made at the fracture site in both fragments. This opens several fresh 
areas of bone surface and theoretically stimulates bone regeneration. 
The limb is immobilized, and a satisfactory result often follows in 
instances of fibrous union. It is hardly possible to eradicate in this 
way a pseudarthrosis. Complete open operation to expose the frag- 
ment ends is a more radical step. All fibrous tissue is removed by 
sharp dissection, the ends are freshened by a saw or chisel, and they 
are brought into approximation by reposition or the use of internal 
splints. Wires, kangaroo tendon, or catgut are used to fasten the 
fragments together, but they are not very efficient in the larger bones. 
i\Iore reliance should be placed in a carefully applied plaster encase- 
ment, put on while the bones are in contact aided by pressure in the 
longitudinal axis. The bone ends may be cut to interlock, and fixa- 
tion can be aided by nails or ivory pegs. If one bone, the tibia for 
example, is shortened by the end trimming, the fibula must be exposed 
and shortened a similar amount to allow approximation, if this type 
of repair is adopted. Foreign material is inadvisable in these cases. 
A Lane plate, however, applied after exact approximation of the 
freshened surfaces, will often promote union, if the subsequent immob- 
ilization is adequate. On the other hand, some cases fail in spite of 
compliance with every rule for the application of the internal splint. 

The very best treatment is the inlay or medullary graft of autogenous 
bone. (See chapter on Treatment.) Several hundred of these cases 
are now on record in the literature, and, if infection is not present 
and radical freshening of fragments is performed, success can be looked 
for in a large percentage of operations. Non-union with pseudarth- 
rosis is the most difficult of all types to cure. The entire mass of the 
false joint must be dissected away. It frequently is attached to nerves 
and bloodvessels, and the process of removal is very tedious. For 
this type I always employ an intramedullary graft. In a limb with 
two bones, one of which is shortened by the freshening process, the 
inlay or medullary graft can be employed with the avoidance of 
shortening the second bone, full length of the part being thus retained. 

On the whole, conservative methods should be used for failure of 
union unless there is obvious reason for radical operation. Loss of 
function and time, necessity for freedom from treatment for economic 
reasons, and the physical and psychological effects of confinement, 
indicate operation. This operation should be undertaken only by 
surgeons of experience in the line of work. Hawley's 53 cases afford 
a means of estimating the value of conservative treatment. Two 
cases resulted in complete failure, 3 were still under treatment at the 
time of the report, and G were fractures of the neck of the femur in 
which the function was fair without corrective treatment. 42 cases 
remained, 31, or 74 per cent., were cured by non-operative means, 
11 were operated on only after conservative treatment had failed. 

In the upper extremity reimmobilization after correction can be 



COMPLICATIONS AND SEQUEL JH 85 

practised, but weight-bearino; cannot be used. Consequently the 
ununited fractures of the upper extremity will more often demand 
operation. Hawley had only 4 successful cases out of 10 treated 
by conser^•ati^•e means, whereas in the lower limb reimmobilization 
plus weight-bearing gave 28 cures out of 34 cases. 

Vicious Union and Deformity. — Vicious union, malunion, and 
deformity under ordinary circumstances, are a reproach to surgery. 
They can nearly always be avoided by careful watching in the course 
of bone healing, if there has been efficient reduction. In some frac- 
tures ultimate deformity must be expected. In Colles's fracture, except 
in adolescents, there is always some degree of permanent deformity 
on account of the crushing shortening of the bone. Fractures of the 
neck of the femur and a certain small amount of overriding in torsion 
fractures of the leg and thigh are to be expected unless an anatomical 
reposition is effected by operative means. INIalunion is caused by 
incomplete reduction, especially by the attendant's failure to use and 
maintain powerful traction in order to bring the fragment in apposi- 
tion. The surgeon must have a well-grounded knowledge of the 
mechanical effect he wishes to obtain. In the leg he must allow for 
the normal slight bowing, if both bones are fractured, and not put 
the leg yerjedJy straight. If the reduction is not in order of the 
physiological alignment of the limb, no splint or external application 
or massage will produce a happy result. Alignment in the limb 
is extremely important so far as final function is concerned. Near 
joints special problems arise in fractures, and esthetic appearance 
must be sacrificed to functional result when the methods to obtain 
the two conflict. Callus and fragments must not interfere with the 
joint motion, and at the same time the alignment of bones must restore 
the limb axis, so that the lines of weight-bearing stress will pass 
normally across the joint and the articular surface will functionate 
without trouble. 

Other causes for malunion are inefficient splinting, too early weight- 
bearing, and lack of cooperation between patient and surgeon. The 
splint or dressing must hold the alignment of reduction and in oblique 
or torsion fractures must also provide for maintaining traction. If 
the patient will not cooperate with the surgeon, if he puts aside his 
splint too soon, or does not lie quietly under the restraint of exten- 
sion apparatus, deformities are to be expected. Too early weight- 
bearing is also of importance. The callus may not be solidified, and 
as it gives under body weight deflections in the supporting line follow. 
About joints, especially after malleolar fracture at the ankle, condylar 
fractures of the femur and humerus and fractures of the shaft of the 
femur, secondary changes of angulation and shortening occur, if too 
early passive motion or weight-bearing is allow^ed. The joint frac- 
tures on which weight is borne too soon become painful, there is altera- 
tion in the bone structure to accommodate the new lines of muscular 
stress and weight-bearing, and buttressing changes result much like 
those found in hypertrophic osteo-arthritis. Fracture througli the 



86 PATHOLOGY OF FRACTURE 

shaft of long bones may liave angular deformity even with an end-to- 
end apposition. This deformity produces shortening and changes 
in the weight-bearing lines which increase the cross strain at the 
fracture site and afl'ect the action of the neighboring joints above and 
below. 

Treatment of vicious union depends on the amount of deformity 
and the age and location of the fracture. If the fracture is recent and 
the callus is soft, manipulation with traction may straighten the 
limb into correct alignment. When joint fractures are concerned, an 
effort should be made to correct the deformity and to place the limb 
in a position of rest until solid union has followed. Should a fragment 
or excess callus interfere with functional movement, open operation 
for removal or for replacement should be undertaken. 

Fracture viciously healed with a solid callus and no overriding and 
shortening can be refractured by an osteoclast or a chisel by an open 
operation through a small incision, after which the limb is straightened 
and reimmobilized. If the deformity has been of long standing, the 
muscle and fascial contractions on the concave side of the limb may 
interfere seriously with correction. In such a case they can be partly 
divided subcutaaieoUiSly before jBnal correction is forced, so that the 
fragment ends are not carried past each other for overriding. 

Open operation is used for osteotomy followed by simple reposition 
or the use of internal bone splints. Complete exposure of the mal- 
union permits an exact knowledge of the fracture. Excess callus 
can be removed, and the bone is chiseled or sawed through and the 
limb brought into line. In some instances a V-shaped fragment is 
cut out as aid in straightening. This is necessary in long-standing 
cases with muscle contraction. Lane plates, nails, or screws are used 
to hold fragments together if they tend to slip about. The best repair 
does not involve the use of an internal splint. Simple reposition lead^ 
to union in a normal length of time. In the making of a straightening, 
the periosteum is seldom completely cut through. If it is widely 
reflected from the ends of the fragments, it must be carefully folded 
or sutured over before the wound is closed. If a plate is applied, it 
should be put on outside of the periosteum. 

Fractures near or into joints are to be judged each on its own 
findings. Pott's fractures with wide dislocation laterally of the 
talus are amenable to operation. The treatment is described in 
the chapter dealing with the bones of the leg. Other joint fractures 
with restricted motion are more safely treated by excision of small 
fragments than by attempts at replacement. A wide range of joint 
motion must be secured and the limb left in fixation until bone 
regeneration has quieted down. 

(/) Nerve Injury and Inclusions,— Nerve injury caused by the 
trauma of fracture is one of the early local complications. The late 
complication is a callus affair. Nerve pressure which causes pain or 
paresis may start in the third to the fifth week. It is caused by the 
callus. The callus may grow around and bury a nerve completely. 



COMPLICATIONS AND SEQUELS 87 

As slirinkage and ossification ensue, the pressure gradually strangles 
the nerve fibers until function is suspended. The radial nerve (mus- 
culospii'al) as it passes around the hiunerus and the ulnar nerve at 
the elbow -joint, are the ones most frequently involved. They should 
be radically freed from the Callus, and transplanted some distance 
away, well ^^Tapped in a sheet of fat. If the operation is aseptic, one 
need have no fear of recurrence. In the last year I have operated on 
six cases of this character. In one the radial nerve had been out of 
function so long that I feared the axones were destroyed at the site 
of pinching. The nerve was severed, therefore, and the compressed 
portion was excised completely, an end-to-end anastomosis of the 
cut portions being possible without a plastic. Fine linen sutures 
through the sheath drew the cut surfaces together. x\fter ten months 
there was a functional return which promised to become nearly per- 
fect. 

Cotton^ has recently called attention to a separate class of nerve 
lesions limited largely to the ulnar at the elbow. There is pain radiat- 
mg doTSTi from the elbow to the last two fingers, some skin numbness 
in this region, and a partial paresis of the intrinsic muscles of the 
hand, shown by weakness and clumsiness in execution of the finer 
finger movements. ^lany of the patients with these complaints 
have not had a fracture at the elbow, but there has been some trauma 
there, and scar tissue has formed which gradually contracted and fixed 
the nerve where it lies in the epitrochlear groove. Movements of the 
elbow, especially flexions, fall on the nerve and cause the symptoms. 
The cure is complete removal of the nerve from the bone bed and its 
transplantation in a site anterior, ^Tapped in a mass of fat taken from 
the thigh or abdomen. I have so transplanted in three instances; 
in one the nerve sheath was red and hemorrhagic in appearance. The 
results are satisfactory. 

Snapping callus, "Cal a ressort," is a callus complication which 
occurs in the radius and fibula. Toussaint^ describes it as an objec- 
tive or subjective click at the callus level, caused by supination of 
the wrist or abduction of the foot. It is caused by friction of an 
angular bone prominence w^hich may be soft or thoroughly calcified 
callus, upon the interosseous membrane. It causes some decrease in 
function of the limb. The roentgenogram will not show it unless it is 
thoroughly calcified. Xo open operation is needed for its removal, as 
immobilization leads to its absorption. 

(g) Development of Tumors. — Causative relation between trauma 
and sarcoma of bone is well established. There is a question, however, 
whether sarcoma follows a fracture. Considering the number of 
fractured bones, osseous sarcomata would be common if fracture 
were the cause. Murphy^ states that he does not believe sarcoma 
follows fracture, but that it follows trauma, which causes pain and 
contuses a bone without breaking it. Most cases which have been 

' Boston, Med. and Surg. Jour., clxxii, No. 13. 

2 Rev. d'orthop., March, 1913. ^ Clinics, i, 780. 



88 PATHOLOGY OF FRACTURE 

reported in connection with fracture are really pathological fracture; 
that is, the sarcoma was i)riniary and the cause of weakening the 
bone. (See chapter on Etiology.) Coley h^s reported a case of bone 
sarcoma which seemed to follow fracture. Griffin^ reported a case of 
sarcoma of the femur, which followed an operation for plating a frac- 
ture. I Ivdve had one case in the jaw. The fracture occurred eighteen 
months previous to the patient's seeking treatment for a tumor of 
the mandible at the same site. The jaw was removed and the sarcoma 
verified. The fracture was healed and the tumor mass spread from 
that area. New growths do rarely appear at fracture sites, from a 
few weeks to many years after the injury. If they are benign in 
character, they are removed for cosmetic purposes or on account 
of pressure symptoms. Every tumor mass after fracture should be 
closel}^ inspected and studied by roentgenogram and the microscope. 
Theoretically sarcoma may result from irritation or from an atypical 
overgrowth of the embryonal cells which form callus. Radical removal 
of the affected part of the bone with transplantation of autogenou,s 
bone to fill the defect is the treatment when metastases and extensive 
local spreading are not evident. 

2. Arrest and Exaggeration of Growth are not Common 
Occurrences. — ^Arrest follows, for the most part, epiphyseal injuries, 
and the subject is discussed under Fractures of the Wrist, where the 
condition is most often found. When a growing epiphysis is injured 
and premature calcification follows, the growing function is lost. 
The bone involved ceases to grow in a corresponding ratio to a com- 
panion bone in the same limb or the corresponding bone of the other 
limb. The result is a curvature and functional loss. Another epiphy- 
sis in the injured bone may take on enough exaggerated growth to 
make up the deficiency, so that ultimately there is no shortening. 
I have had no cases of cessation of growth after fracture of the 
epiphysis of a long bone. 

Exaggeration of growth is seen in the patella. After fracture, or 
even after trauma, which does not produce fracture, this sesamoid 
enlarges. The new growth is caused by proliferation beneath the 
periosteum, and in some cases the process of ossification extends into 
the patellar and quadriceps extensor tendons. This is comparable 
to parosteal bone growth, ossifying myositis, etc. Large bony growths 
from callus are really excess callus formation. When the whole shaft 
of a long bone thickens and presents an appearance of exaggerated 
growth, the first thought must be of an osteomyelitic or a syphilitic 
process. A roentgenogram will aid in establishing diagnosis. True 
giant growth may be localized in one limb and may not be noticed 
until after a trauma. I have seen one case of localized giant growth 
affecting the leg of a boy about eight years old. Both bones are 
affected, and the soft parts are also. There is no edema or changed 
appearance, other than the increased size, and function is normal. 

1 Med. Record, 1913, p. 650. 



i 



COMPLICATIOXS AXD SEQUEL.^ 89 

3. Xeighborixg Joint Complications. — Xeighboring joint com- 
plications are manifested by stiffness and restricted motion. These 
complications do )iot incJudc the results' of (irticular fravinrcs, but are 
caused l)y local conditions in the limb extending from the fracture 
site or by treatment. 

If the fracture is near a joint, unrecognized fissures may extend to 
the joint. Hemarthroses, distention of the joint, or even suppuration 
may result. Chaput^ suggests that there are many unsuspected 
instances of suppurative arthritis after fractures, and advises the 
injection of a solution of methylene blue by joint puncture to dis- 
tend the synovial membrane slightly. Coloration of the pus at the 
fracture site proves the existence of a connection. 

Stiffness and restriction of motion in other than joint fractures may 
be caused by conditions arising within the joint, about the joint, or 
in the limb as a whole. The conditions arising within the joint are: 

(fl) Hemarthrosis, which causes a distention of the joint capsule 
and leads to subsequent weakness or the formation of adhesions within 
the joint. This capsular weakness is counteracted by contraction of 
periarticular structures which ultimately causes restriction of motion. 

ih) Suppurative arthritis of hematogenous origin rather than of 
extension through fissures mentioned in the preceding paragraph. 

(c) Traumatic arthritis with or without effusion characterized by 
pain and much loss of function and followed by great restriction of 
motion. The pathological result includes intra- and periarticular adhe- 
sions and contraction of the capsular structures. 

{d) Remote changes within the joint induced by positions of mal- 
alignment of a limb. In the leg these often lead to the buttressing, 
bony changes described previously, which are much like osteo-arthritis. 
These are particularly prone to appear in elderly people, so that the 
relative effects are greater in the old than in the young. 

The conditions about the joint which cause stiffness are: (a) Con- 
traction of the capsular ligament following stretching from prolonged 
extension as a Bucks, or the contraction and atrophy subsequent to 
non-use and long immobilization. The tissues may be shortened 
by permanent cicatricial change from infection of open fracture, or 
by aseptic inflammation. 

ie) Contraction and fixation or stiffness in the pericapsular tissues 
such as muscles and tendons which become adherent or atrophied. 

Conditions arising in the limb as a whole are edema and circulatory 
interference from any cause such as a large callus, tight splints, or 
vessel injury, shortening of muscles and tendons from disuse, atrophy, 
or adherence to callus or nutritional disturbance, such as in Volkmann's 
contracture. 

The treatment of neighboring joint complications is largely that 
of prophylaxis. Early steps must be taken to diminish swelling and 
edema of a limb. Hot and cold applications, aspiration of joint 

1 Presse Morlipale, Paris, xxiii, No. 10. 



90 PATHOLOGY OF FRACTURE 

effusions and hemorrhages, and incisions through the fascia may 
be used. The parts not immediately involved or whose immobiliza- 
tion is not essential to proper treatment of the fracture must be left 
free. This is essential in the hand. The fingers must be free when- 
ever possible and their use and motion encouraged from the first. 
Active and passive motions of joints must be used when no pain 
or reaction is caused, not before. Undue stretching of the joint cap- 
sule or prolonged immobilization in a fully extended position of the 
joint must be avoided. Time, massage, passive and persistent active 
motions and use will cure most cases of joint complication. 

4. Muscle and Soft Part Changes. — ^Muscle and soft part 
changes have been partly mentioned in preceding sections. The skin 
and subcutaneous fat may show atrophy. The skin seems thinned and 
anemic, or in some cases shiny and red or cyanotic. The muscles 
are distinctly atrophied if a long immobilization has existed. The 
muscles lose elasticity and bulk, and they niay be fixed to callus, torn 
fascial planes, or periosteum. When a permanent dressing is removed 
and the patient starts to use the limb or to expose it to normal sur- 
roundings, there follows swelling of a few days^ duration. Use and 
massage overcome this. Young persons overcome the atrophy, which 
is nearly always one of disuse and rarely dependent on nerve changes. 
In elderly persons massage and electricity often fail to make complete 
restoration. 

5. Bloodvessel Complications. — Bloodvessel complications are 
nearly always early. Late changes may be found in veins when the 
patient begins use of a limb. Callus or malposition may cause cir- 
culatory interference and passive congestion with enlarged veins. 
Late thrombosis and embolism are rare, but there are cases recorded 
in the literature. Embolism of the pulmonary artery is the one most 
feared. I have seen one case in the third week after fracture of the 
femur. Small emboli, often septic, have been found in the lungs or 
pleura before thrombosis in the leg was suspected. Le Conte's inves- 
tigations of fat embolism seem to disprove the danger of pneumonia 
from this source. The hypostatic congestion is probably the most 
important factor. 

Late gangrene may follow injury of the arteries which results in 
thrombosis or in circulatory disturbance in persons with sclerotic 
vessels. Age has much influence in the bloodvessel complications. 
Traumatic aneurism is rare, but occurs in the popliteal after fracture 
of the femur. It may be late in appearing when the fracture is unre- 
duced and the vessel is stretched over the lower fragment. 



chapter iv. 
sy:\iptoms, signs, and diagnosis of fracture. 

SYMPTOMS AND SIGNS OF FRACTURE. 

Whex we speak of symptoms of fracture we mean something sub- 
jective, lying wholly within the patient's consciousness. By signs we 
mean something objective rather than subjective. Signs, however, 
often overlap into symptoms. Pain may be simulated so that the 
surgeon cannot rely on the evidence furnished by it, but the trained 
examiner in doubtful cases depends less on the patient's complaint of 
pain and more on the elicitation of signs of suffering on reiterated 
pressure or jarring of the suspected part when the patient's attention 
is distracted. Crepitus also may be subjective; that is, it may be felt 
by the patient and not by the surgeon. Symptoms and signs may be 
enumerated as: 

1. Pain. 

2. Loss of Function. 

3. Deformity. 

4. False ^Mobility. 

5. Crepitus. 

1. Pain. — Pain is the most important finding in fracture. It is con- 
stant except in some instances of pathological fracture or in conditions 
in which normal enervation is lessened. When the patient keeps the 
affected part quiet after injury, the amount of pain varies with the 
amount of injury and local reaction. Fracture caused by direct violence 
with bruising and laceration of the soft parts, with swelling and hemor- 
rhage, would be expected to cause much spontaneous pain. Incomplete 
fracture and fracture from indirect violence will probably have less 
spontaneous pain at first. All unrecognized fractures cause pain, if 
use of the part is persisted in. Pain symptom is usually elicited on 
active and passive motions of the bone. If a long bone of a limb is 
broken, it becomes painful when active contractions are made of the 
muscles attached to it, either in functional use or in resistance against 
movements which are applied as tests. Efforts to extend the forearm 
held by the surgeon cause pain in the ulna when it is fractured, and 
the broken radius is painful when flexion efforts are restricted. Twist- 
ing or rotary movements applied gently to the arm or leg elicit pain 
at the fracture site. The jarring of a bone by slight knocks in its 
longitudinal axis or in the transverse axis by a percussing finger tapping 
along its continuity causes pain. Near joints, pencil or digital pressure 
applied over the bone will discover in obscure fracture a recurring 
point of pain. The pain of the bone lesion, which can be differentiated 



92 SYMPTOMS, SIGNS, AND DTAGNOSIS OF FRACTURE 

from tlio ])a infill injury of the soft parts, is persistent and lasts for ten 
to fourteen days. Its prominent eharaeteristie is that it recurs in the 
same place. Some fractures give no other symptom than pain. A 
crack across the radius at the wrist, or a green-stick fracture of the 
clavicle, or a crack in the fibula just above the ankle, all fail to give 
deformity, crei)itus or false motion, but do give this recurring pain. 
This finding is consequently the most valuable and the easiest obtain- 
able in fracture. The roentgenogram is the only sure evidence that is 
comparable to it, and then a poor exposure will fail to reveal a fracture 
which can be diagnosed by pain symptoms. 

2. Loss of Function. — Loss of function is variable, depending on 
the extent of the fracture and complicating effects of the trauma. 
The functional disturbance may arise from two sources: from the lack 
of support of the part caused by loss of continuity of the bony skeleton, 
or from actual pain or fear of pain. Bruises and contusions involving 
muscles, tendons, periosteum, and joint surfaces often cause temporary 
loss of function in a limb. This temporary disability ceases under 
simple therapeutic measures. The functional disturbance of fracture 
is prolonged. Possibly it should be called a disturbance rather than a 
loss of function, particularly as applied to incomplete and obscure 
fractures. Complete fracture of the bones of a limb leads to unmistak- 
able loss of function. 

Cases of fracture which have not been diagnosed often show a 
functional disturbance of greater importance than the type of fracture 
warrants. This finding outlasts pain. 

3. Deformity. — This sign concerns gross deformities apparent to 
inspection of the part and the various displacement of fragments 
described in the chapter on Pathology. Shortening, angular deformity, 
or overriding may be apparent on inspection of a part. No observation 
of deformity is of value as a symptom or in diagnosis unless previous 
injuries are considered and the part is compared carefully with the 
corresponding uninjured portion of the body, if there is one. Mensura- 
tion in both longitudinal and transverse axes and circumference 
betrays the existence of deformity. Length is determined by measure- 
ment from fixed bony points on the skeleton which are palpable or 
subcutaneous. Where there is much subcutaneous fat these points 
are difficult to locate exactly, and there must be allowance for error 
on the surgeon's part and for variation in the length of limbs. (See 
Fractures of the Femur.) Two limbs subjected to measurement for 
comparison must be in the same relative position toward the trunk, 
making an identical angle with the long axis of the body. If one is 
distended with effusion or inflammatory exudate, these conditions 
will influence measurements. 

These same swellings also cause modification of the external appear- 
ance of a limb and produce deformity themselves, or enhance the 
deformity of fracture. Subfascial hemorrhage and extravasation 
increase the transverse diameter of a limb and shorten its length if 
the bone continuitv is lost. 



SYMPTOMS AND SIGNS OF FRACTURE 



93 



Ecchymosis from fracture is also a valuable sigu, particularly in the 
obscure fractures about joints or deep structures, like the small bones, 
of the wrist and ankle. The discoloration does not appear at once 
unless the superficial soft parts have been damaged; it shows in the 
com'se of a few davs and mav last for three or four weeks. There is 




Fig. 22. — Bleb formation after ankle fracture. Practically no deformity present. 

tendency for the blood to burrow in the direction of the fascial and 
muscle planes and appear at great distance from the fracture area. 
Bleb formation is present in many cases (see Figs. 22 and 23). 

4. False Mobility. — False mobility or a false point of motion is 
pathognomonic of fracture when it is found existing in any part of a 




Fig. 23. — Bleb appearing on fourth day after ankle fracture. 



bone when motion does not exist normally. This sign is not demon 
stral)le in all fractures. In impactions, as depressions of the skull 
vault, in fractures of the smaller bones of the body, as in the wrist 
and ankle, or in fractures near joints where one fragment is small and 
is held in place by untorn ligaments, one would not be able to find a 



94 SYMPTOMS, SIGNS, AND DIAGNOSIS OF FRACTURE 

false point of motion. Some bones are slightly elastic and give an 
impression of slight mobility which may be misleading. The ribs and 
the sternum, particularly the ensiform process, are examples. 

A false point of motion is demonstrated in complete fracture of a 
limb by simple raising of the part gently by a hand placed under the 
site of fracture. Angular deformity, pain, and sometimes crepitus 
are at once produced. The fractured bone may be grasped between 
the fingers of both hands, one above and one below the break, and the 
fragments are moved in opposite directions to establish looseness. 
The distal end of a long bone may be grasped and the limb rotated, 
the fingers of the other hand resting on the proximal fragment feeling 
to determine the false point of motion. The fragments may require 
rocking with considerable force, or small fragments near joints can be 
grasped between the thumb and index finger and moved in the direction 
of the plane of fracture. Under some circumtances repeated attempts 
are necessary to assure the surgeon that he is dealing with false motion. 
Abnormal motion in fracture just below the head of the humerus, 
radius, and femur is searched for by the attendant rotating the shaft 
of the bone and endeavoring to feel the head to ascertain whether 
it takes up the shaft motion or fails because of lack of continuity. 
Wide rotatary movements are not needed and lead to confusion, 
because the head may be moved by the attachment of untorn ligaments. 
Infractions also cause the head to move with the shaft and lead to 
error. MovemiCnts of skin and soft parts over the bone must not be 
confused with mobility of the osseous structure itself. 

5. Crepitus. — Crepitus is defined as a grating sound or a similar 
tactual sensation perceived by the patient or the surgeon as he manipu- 
lates the bone. It is caused by the broken ends being rubbed together 
and depends on the previous sign of mobility of the fragments. The 
eliciting of even the slightest click of unmistakable crepitus is positive 
evidence of fracture. Experience leads, to quick recognition of this 
valuable sign, and it can often be felt by gentle and nearly painless 
manipulation, which should not be repeated if positive results are 
obtained. When gentle motions fail, forcible exertion is not indicated, 
especially if pain is induced. Muscle spasm from pain may hold frag- 
ments immovable, and diagnosis of fracture can be made on other 
findings, or an anesthetic can be given to permit full examination. A 
condition of normal joint crepitus which is present in many persons 
may confuse the examiner. The joint crepitation is transmitted along 
the bones which enter into the articular formation, so that motion 
will give a false feeling of crepitus. This feeling is generally softer 
and smoother than the sharp click or grating of fractured osseous 
surfaces and can be eliminated by experience and by testing a corre- 
sponding uninjured part of the body. 

Other means of obtaining crepitus are the use of the flat surface 
of the palm over the chest when fractured ribs or scapulae are concerned 
and direct auscultation with the stethoscope. Deep inspiration or 
pressure movement of the ribs and scapula may reveal a crepitus not 



DIAGNOSIS OF FRACTURE 95 

found in other ways. Certain types of fracture are not likely to give 
crepitus for obvious reasons. They are: 

1. ^Marked overlapping. 

2. Separation of fragments, as in the patella and olecranon. 

3. Impactions and locked denticulate fragments found in Colles's 
fracture and in the femoral and humeral neck. 

4. Incomplete fracture, as sprain and green stick. 

5. Bucklins: fractures. 



DIAGNOSIS OF FRACTURE. 

Diagnosis is made on a combination of the above symptoms and 
signs. All may be present in a fracture; only one, pain, may be 
present in others. No diagnosis should be made by rule. The examiner 
must use every means at his disposal to verify or disprove fracture. 
Many instances of broken bones are not diagnosed and are conse- 
quently improperly treated, because all the signs are not found. This 
is particularly so in regard to crepitus, which should be relegated to 
its place of relative importance, namely, the last. Grave errors in 
diagnosis and risks of liability are run by insistence upon this sign as 
essential to clinical diagnosis of fracture. The greatest reliance can 
be placed in pain, in recurring soreness and tenderness at one point 
on repeated examinations. If there is no other plausible reason with a 
history of trauma, diagnosis of fracture is quite safe. Rarely other 
conditions may be mistaken. As I write this I have in mind a case 
admitted to my service in the Cook County Hospital. He is a young 
lad who has injured his left hip in a fall. No satisfactory physical 
examination could be performed by the doctors admitting him to the 
hospital, as he would T\Tithe about with pain if attempt was made to 
examine the right hip. The thigh is held in flexion and some inward 
rotation. There is evidently slight active use of the leg, and a diagnosis 
of fracture dislocation was put on the admission card. A short observa- 
tion aided by a roentgenogram was sufficient to prove that the condition 
was an acute infectious epiphysitis of the upper end of the right femur. 

Examination of the patient must be thorough. History of any 
previous accidents and of the exact nature of the present trouble must 
be obtained. Evidence of contusion, soiled clothing, abrasions, or old 
injuries must be searched for, and the patient's statement must be 
weighed in the light of their evidence. The clothing of the injured 
and corresponding part should be removed for complete examination 
and comparison. One of the most helpful points of evidence in complete 
fracture is the inability to retain a reduction which may be easily 
made. This differentiates from dislocation. Multiple fracture is 
frequently overlooked. All manipulations must be gentle and must be 
undertaken after securing the patient's confidence. lloughness 
leads to increased pain and local reaction about the fracture site. 
Muscular contraction and spasm, increased displacement, the separa- 
tion of an impacted or dentate fragment when that might not be wished 



90 SYMPTOMS, SIGNS, AND DIAGNOSIS OF FRACTURE 

for, result and may cause embolism, nerve injury, or bloodvessel 
damage with gangrene. When satisfactory examination cannot be 
made otherwise, an anesthetic may be given, but reduction and treat- 
ment must be prepared for at the same time to avoid repetition of the 
anesthetic. Rough manipulations must be avoided. 

Reference is made constantly in this text to the value and use of 
the Roentgen rays, and the illustrations used for graphic description 
of the various fractures are tracings of roentgenograms. It must be 
said, however, that too much reliance should not be placed on the 
roentgenogram, nor should it be allowed as legal evidence in fracture 
cases. Too many factors enter into its make-up. Time and angle of 
exposure, the skill of the individual making the picture, and the 
experience of the one interpreting the picture allow a great divergence 
of opinion. Knowledge obtained from the plates should be applied 
by clinical examination before full diagnosis is made. Complete 
knowledge of the extent and planes of fracture cannot be obtained 
from one plate. As prescribed in ankle fractures, a roentgenogram 
in two planes should always be made, if any plates are possible, and no 
definite knowledge of impaction at the hip or complete displacements 
at other sites should be asserted without stereoscopic views. The one 
interpreting the plate should have a wide knowledge and experience 
in bone pathology, coupled with an anatomical knowledge of growth of 
bone and epiphyses and their appearance in roentgenogram. Routine 
use of the Roentgen rays preliminary to the treatment of all fractures 
is impossible and not essential. Palpable deformities can be reduced 
early with much relief to the patient without a wait of hours or days 
for a picture. A plate made after reduction, when the patient is 
in condition to be transported to the room for exposure, or can walk 
to a laboratory, is very helpful if the reduction is not complete. Most 
dislocations are reduced when first seen by the surgeon, and roentgeno- 
grams of them later are for the purpose of confirming the reduction 
and of checking upon some of the small fractures that accompany 
them. Obscure injuries and dislocations, suspected or known fractures 
of the pelvic, skull, wrist and ankle bones and about joints like the 
hip and shoulder, are wisely subjected to Roentgen examination if it is 
convenient. 

A roentgenogram taken to show end-results or late in the course of 
a fracture has no value except in those cases of failure of union to 
determine the amount of callus or to help decide on operation for 
malunion. The ultimate test of the fracture result is functional and 
not anatomical. Anatomical reposition seldom occurs except in open 
operation, and not always then. If the patient secures a functional 
result without gross deformity, no Roentgen examination is necessary, 
and slight displacements which are present in a large majority of cases 
might be misinterpreted by unskilled observers and lead to trouble. 
These displacements become effaced in the course of time when 
functional use readjusts the bone structure in accordance with Wolff's 
law. 



CHAPTER V. 
TREATMENT OF FRACTURES. 

Ix many divisions of medical science we have devoted ourselves, 
to the refinements of laboratory diagnosis, to brilliant surgical exposures 
of lesions or to an equally masterly repair of them. Fracture treatment 
has suffered from lack of this attention. If one studies Hamilton's 
Fractures and Dislocations, it seems almost impossible to believe that 
the older masters of that type of surgery were able to know as much 
of the refined detail of fractures as they did without the help of the 
Roentgen rays. A large majority of newly graduated medical students 
today have a wonderful and thorough knowledge of intricate pathological 
processes and laboratory tests, but many of them are very deficient 
in knowledge of practical fracture treatment. The roentgenogram, 
asepsis, and operative treatment have deprived the profession of many 
members who without these aids would have become expert diagnosti- 
cians of unopened traumatic bone lesions. It might also be said that 
treatment has been neglected until Lane and others have forced a 
desire for better results on the profession and the public. There is 
now a reversion to former keenness of diagnosis. Open operation and 
better knowledge of immediate pathology have really sharpened 
the practices of non-operative care, and good can be traced from the 
many unfortunate operated cases of the past few years. The subject 
of neglect of fractures, the necessity for attention to them and for 
training of men in that field has been discussed in most of the influen- 
tial medical societies of the world and caused a tremendous outpour 
of literature in the last ten years. 

Treatment may be divided into: 

Immediate treatment; reduction, the factors obstructing and favor- 
ing it, and means of obtaining it; traction, fixation and difierent 
types of splints used to maintain it; massage and accessory treatment. 
Methods which involve a cutting operation, and the arguments for 
and against such procedure, are contained, as much as they can be 
separated, in the chapter on Operative Treatment. 

IMMEDIATE TREATMENT. 

It is artificial to speak of first aid, or immediate treatment and 
permanent treatment })ecause the two merge, and in any treatment 
of the fracture itself in the beginning, the surgeon should bear in mind 
the indications for permanent cure and restoration of function. Every 
case must be judged separately and certain factors must be weighed 



98 TREATMENT OF FRACTURES 

in non-operative as well as in operative treatment. The surgeon must 
consider: (1) what is the best treatment for the fracture before him 
from the standpoint of the patient. The patient's age and physical 
condition, his environment and the exact position of the fracture 
itself must be weighed; (2) what method of treatment will cause 
the least distress and pain for the patient after its application; (3) 
what method will give shortest disability and the best function; 
(4) what are the surgeon's own limitations in regard to ability in 
diagnosis and treatment; (5) what are the medicolegal aspects of the 
case. 

As regards the patient, his age and physical condition are im- 
portant factors. The aged and those with weakened cardiac action 
or organic diseases cannot be subjected to recumbent rest in bed 
for fear of pulmonary and other complications. The bones under 
certain conditions of age and disease do not regenerate quickly, nor can 
weakened patients withstand the weight and confinement of massive 
splints and dressings. Light splints made of moulded plaster, 
aluminum, wire and leather may be indicated. Nervous patients 
will not endure splint confinement nor long periods of extension. 
Complications of other injuries and shock of accident must be kept 
in mind, and no treatment or manipulation which will cause more 
pain or induce "noci association," as described by Crile, should be 
attempted. Any illnesses or dyscrasias should be inquired into. 
Consequently the first step is a most painstaking general examination 
or survey of the patient. This examination should be gentle, the symp- 
toms of fracture should be solicited without disturbance, and although 
treatment from the very start must look toward restoration to normal, 
it is better to postpone thorough diagnostic examination of the site 
of fracture until one is ready to proceed with reduction and fixation, 
or until the other factors have been weighed. Rough manipulation 
causes pain and reflex muscle spasms which defeat attempts to obtain 
diagnostic information and interfere with reduction. When the 
patient is at a distance from the surgeon, in a farm house, or so located 
that observation of progress of the condition cannot be safely carried 
out, the type of treatment must be of such character that it will 
be safe under the existing circumstances. When possible, hospitali- 
zation of fracture cases should be insisted upon until recourse to 
roentgenogram is obtained and the subsidence of acute conditions 
permits safe dressings out of the surgeon's immediate reach. 

The earlier the patient is seen after accident, before swelling and 
pain with muscle spasm have developed, the easier it is to make quick 
examination and an accurate diagnosis. The exact type of fracture 
should be determined from the history and the examination. Local 
complications must not be overlooked. Small lacerations of the skin 
or fascia ma}^ not seem to penetrate to the bone, but they very fre- 
quently do by indirect routes and should be viewed with suspicion. 
Major fractures are better diagnosed and treated under anesthesia. 
If this is desired and transportation to another place or hospital is 



IMMEDIATE TREATMENT 99 

necessary, the immediate dressing should be one which fixes the limb 
in the position of displacement and holds it firmly. Even this treatment 
must not be applied until the surgeon is assured that the fragment 
ends will not injure important nerves and bloodvessels. 

Some cases which come under the classification of "operative 
reduction" will need exclusion from the line of simple treatment at 
once. Many of these, however, are not subjected to immediate opera- 
tion, and a dressing is applied for protection and security against 
pain, or extensions of different kinds are used to preserve muscle 
length and to avoid spasm. 

Reduction. — ^If reduction can be made, the immediate treatment 
is pursued in direct line of a permanent one; that is, the splint or 
fixation is used which will cause the least distress to the patient in its 
application and which will give the quickest and best end-results. 
No one splint should be used for certain types of fracture unless that 
splint is open to modification to suit the individual case. The splint 
should aim toward permanent correction in accordance with the 
previous statements; it should afford protection from outside jars and 
exposure; it should rest the part, and it should lessen the pain and the 
danger of complications. 

The surgeon should know his ow^n limitations in a diagnostic and 
therapeutic way, that he may not be led into errors of ignorance which 
will cause unhappy results to the patient and himself. 

The medicolegal aspect must also receive attention. This involves 
relations between the surgeon and patient, between the surgeon and 
employers' liability laws and insurance. State accident insurance, and 
various fraternal organizations and corporations. The relation most 
important to the surgeon is his own liability to the patient to exercise 
a reasonable degree of skill. A large percentage of personal damage 
suits against medical men arise from fracture cases. I have been asked 
questions on the status of first aid and found an interesting concrete 
example in the Queries and Minor Notes column of the Journal of 
the American Medical Association} The questioner wished to know 
if "first aid" in fractures had been defined in his own State (South 
Dakota) or Illinois, because it concerned the matter of a fee for a 
roentgenogram and reduction of a specific case. The insurance com- 
pany concerned was not willing to pay for these things as "first aid." 
The Journal defined first aid as the temporary measures carried out 
in emergencies by anyone, layman or physician, preliminary to the 
institution of a definite line of treatment by the physician in charge 
of the case. They believed that "first aid" ceased and definite treat- 
ment began when the patient had arrived at his home or a hospital 
and had been turned over either to his own physician or to the hospital 
surgeon, or wished to continue the services of the physician first 
called. In large cities where many persons who suffer accident are 
transported to hospitals at once there is no "first aid" at all, unless 

1 August 29, 1914, Ixiii, No. 9. 



100 TREATMENT OF FRACTURES 

the transportation may be so called, definite treatment being instituted 
in the first services performed for the person at the hospital. 

Immediate treatment after the patient is settled in some permanent 
quarters should be gentle, and it should aim to restore the fragments 
to their proper place; that is, the axis of the limb or the body relation 
should be made natural, to prevent fragments from sticking through 
the soft parts or doing other harm. Local reaction and inflammation 
should be controlled by applications of cold. Complications must 
be guarded against, or treated when present. Finally the treatment 
merges into permanent care to keep the reduction in place until 
healing has followed. 

Reduction is defined as the replacement of the displaced fragments 
into a position which favors prompt bony union and return of function. 
This is commonly known as ^'setting" of the fracture. Reduction 
is not always such a simple matter as it sounds. It may be done 
immediately by simple manipulation and expedients, or it may result 
from several strenuous attempts often by means of anesthesia, or 
after a considerable period of extension by weight or mechanical 
traction. In some fractures early reduction is not possible or necessary; 
in others we have come to learn that operation is the best treatment, 
and although some cases may lie in one division, complications which 
are present may change their aspect and treatment to that of another 
class. 

The character of non-operative reduction varies. It is rarely, even 
in the most favorable cases, an absolute reduction to former position 
of the bone fragments. This absolute reduction is termed an anatomical 
reduction or reposition and is seldom seen except in open operation. 

The most important feature of reduction is restoration of the normal 
axis of the limb, particularly in the leg. We do not comprehend the 
significance of Wolff's law mentioned in the general chapter on Bone 
(p. 18). I quote Mr. Robert Jones in this connection:^ "The internal 
structure of bone and then its outward appearance are adapted to 
the strains to which it is subjected and to the function it performs, 
and the structure varies to meet alterations both in strain and function. 
Normal bone, in fact, is structurally fortified at that point where 
most work is required of it. By deflecting strain to another part the 
structure is correspondingly strengthened there and weakened where 
it is no longer wanted. The pathogenesis of deformities is therefore 
functional. What is required is a knowledge not so much of its anatomy 
as of its movements (of a joint or limb) and the directions of normal 
lines of strain during muscular exercise." Though reduction may not 
be anatomical, it is in a large majority of instances serviceable and 
leads to happy final result. The one brilliant exception which often 
gives perfect anatomical reduction by non-operative means is epiphy- 
seal separations. With care it is possible in the wrist and ankle, 
especially, to obtain perfect reduction of epiphyseal separations. 

1 Proc. Roy. Soc. of Med., Surg. Sec, December, 1910, 



IMMEDIATE TREATMENT 101 

Reductions are early or late; there is much to be said in favor of early 
reduction, because in recent injuries the muscles offer less resistance 
and the etl'usion of blood and lymph has not yet distended muscles, 
fascial boundaries, and skin to cause shortening and deformity of the 
limb. Consequently in accordance with the previous statements 
there should be no delay in reduction. 

There are certain factors which cause difficulty in reduction. These 
are: 

1. Extreme displacement of fragments which are pulled on by 
muscles or forced far out of position by the trauma. 

2. Interposition of muscles, fascia, or small bone fragments between 
the fractured parts. 

3. Long spiral fractures with overriding of fragments, comminution, 
impaction, and mashing destruction of cancellous bone. 

4. Other mechanical hindrances as muscle spasm and primary 
effusion beneath a heavy fascial envelope. 

5. Beginning callus or secondary infiltration of the parts at the 
site of fracture. 

6. Other injuries which are more important in a general way. 
Local injury of bloodvessels and nerves, or the formation of blebs, 
may make impossible the application of traction necessary for reduction 
or of apparatus to hold it. 

Factors which favor reduction are: 

1. Simple type of fracture with little displacement. 

2. Little swelling and local reaction. 

3. Early efforts, before muscular contraction and swelling interfere. 

4. Anesthesia, local or general. 

Not all fractures result in displacement and consequently not all 
need reduction. Those not needing reduction are usually linear frac- 
tures through the large bones. The skull, the ilium, or the scapula 
also furnish examples. Other bones, like the ribs, or one of two bones 
in the forearm and leg, may be broken and held in place by the un- 
injured companion bone. If we include the possibility of operative 
aid, practically no fracture displacement is irreducible. Some may 
better remain unreduced where there are obstacles in the way. Dis- 
placed fractures of the pelvis which will not yield to manipulative 
efforts are of this type. Impacted fractures of the femoral neck in 
some elderly people are considered irreducible from choice, and others 
with impaction and little displacement are often not disturbed for 
fear of increasing the deformity. 

Fractures about and into joints are a law unto themselves. Most 
of these are to be placed in the operative class, because their reduction 
is often dependent on the integrity of the ligaments, and these may 
be torn or injured so that they are not available for reductive traction. 
They should be given very early reductive treatment, which if not 
shown satisfactory in the roentgenogram must be supplemented by 
operation. If reduction cannot be anatomically perfect, it must be 
that which will fix the joint in position to render the greatest use. 



102 TREATMENT OF FRACTURES 

A \(M-y slight (loforinity in a joint fracture may result in disproportion- 
ate disability. Tliis is because a cliange or tilt in a fragment encroach- 
ing on the joint surface may change the joint axis to an extent which 
causes deviation of the articular surface and thus loss of function. 
It is therefore more important to restore joint fragments to their 
normal axis than it is to restore shaft fragments. The tilting of the 
joint induced by one short side or surface must be avoided. In shaft 
fractures we look for compensatory bone changes in accordance with 
Wolff's law, but about joints these favorable changes do not appear. 
Anatomical reposition may not be secured in shaft fractures and in 
most cases is really not sought, but functional reduction is desired. 
We may then conclude with Ashhurst^ that if open treatment is required 
for old diaphyseal fracture, it is more often because of non-union 
or of concurrent lesion of the soft parts than because of rare malunion 
which in time cares for itself. Likewise many fractures have to be 
treated in accordance with general anatomical knowledge. We attempt 
to bring one fragment which we can control in line with another which 
responds to the pull of muscles and is displaced. Fractures of the 
upper third of the femur and the surgical neck of the humerus are 
cared for on the basis of muscle pull on the upper fragment which 
rotate, abduct, and elevate it. However, we cannot state positively 
what position will be required, because anatomical laws do not apply 
to many fractures. Some muscle attachments are torn out, other 
muscles may be in spastic contraction, and those still attached may 
produce pulls or cause distortions contrary to anatomical expectation. 

Deformity and disability are not always the result of insufficient 
reduction. Striking examples of these facts in spite of a seemingly 
perfect reduction are seen in wrist-bone fractures and Colles's fractures, 
which may be very accurately replaced and yet the crushing of the 
cancellous bone of the radius may produce permanent shortening 
of the bone which no manipulation will restore. Similarly in other 
fractures, even when anatomical reduction is made by operation, 
permanent bone changes may occur. The trauma causing the frac- 
ture may induce periosseous changes which involve joint surfaces or 
surrounding tendons and muscles and which lead to a permanent 
impairment of function. 

When treating fractures we are apt to overlook lesions of the soft 
parts. They are always present and are frequent cause of later 
disability. In open fractures we do not neglect them, because we fear 
infection more than any other thing, and the bone lesion becomes 
secondary. These disabilities from lesions of the soft parts can be 
forestalled in treatment, if we insist on early active movements and 
functional use when the bone union will tolerate it. Massage, including 
effleurage and petrissage, should be used from the first to reduce edema 
and swelling and to prepare neighboring joints for early functionating. 

It is necessary to say, in view of the development of common use, 

' Am. Jour. Surg., New York, 1915, xxix, 114. 



IMMEDIATE TREATMENT 103 

that the Roentgen rays should be used in every traumatic case where 
fracture or dislocation is suspected. This is possible even in remote 
rural districts where electric current may be furnished by a storage 
battery, or from an automobile. From the medicolegal standpoint 
a roentgenogram is of the greatest weight. The influence on treatment 
is also far reaching. Study of Roentgen pictures taken for injury of the 
upper end of the femur reveals many surprising points in the bone 
pathology, and if a general rule is followed in treatment by abduction 
or elevation, the surgeon will frequently cause increased displacement 
of split or broken-off lesser trochanters and other parts. To treat 
fractiu-e intelligently, we should know the relative position of the 
fragments in every case both before and after attempts at reduction. 
This knowledge may lead to repeated attempts to better the displace- 
ment and bring about a final result much more satisfactory to the 
patient and surgeon than that obtained by unchecked methods. 
Estes^ says that accurate adjustment of fragments was never obtained 
in fractures treated by older methods. This is not so much an argument 
in favor of operative reduction as it is of checking attempts at reduction 
by the roentgenogram until the desired position is secured, or the 
case enters the operative class. 

The use of the fluoroscope to control reduction probably has some 
future, especially in hospital work. There are limitations to it that 
everyone who has attempted to use it realizes. It is difficult to see 
distinctly small fragments near joints, and when a reduction is made 
without a fracture table or other mechanical apparatus there is no 
surety that the reduction gained is held during the application of the 
splints. Fluoroscopic examination through plaster casts is unsatis- 
factory. In the chapter on Operative Treatment the method of 
pinning fractures through a cannula with the fluoroscope is mentioned. 

Means of Reduction.^ — Anesthesia. — The need of anesthesia must be 
decided by the surgeon before reduction is attempted. It is wiser 
to use an anesthetic to obtain an early complete reduction than it is 
to cause the patient pain and fear by efforts of reduction without it. 
Repeated attempts cause increased local infiltration and edema. 
There is subfascial swelling, which shortens and broadens the limb 
and defeats efforts at lengthening by traction to overcome deformity. 
^^^len the limb is pulled, the capacity of the fascial envelope is reduced, 
there is greater pressure within it, and the subsequent pain induces 
tonic muscle contraction. The circulation may also be interfered 
with, so that it is better to let all local swelling subside if repeated 
attempts at reduction are anticipated, or an anesthetic should be used 
early. Satisfactory early reductions minimize pain, they favor the 
best circulation, and there is no muscle spasm and contracture to be 
combated as in late setting. 

Anesthesia may be general or local. Nitrous oxide gas is often 
sufficient to produce relaxation and freedom from pain in non-alcoholic 

> Am. Jour, of Surg., xxviii, No. 1. 



104 TREATMENT OF FRACTURES 

])atioiits. Tlio ether raiisch is very helpful, and surgical anesthesia 
with ether is necessary when mechanical traction and traction-fixation 
are to he applied. Local anesthesia was used in America a quarter of a 
century ago by Conway. Quenu and Braun^ inject suitable quantities 
of novocain by means of long thin needles inserted at the frag- 
ment ends. This has its greatest value in the leg or about the ankle. 
Dollinger- describes a reduction of a fracture of both bones of the 
leg, after the inducing in this manner of a zone of local anesthesia 
l)roximal to the fracture. For upper arm fractures the best pro- 
cedure is a blocking of the brachial plexus. Kulenkampff^ has 
described this method, with the needle inserted above the clavicle. 

The means of reduction are direct pressure, rotation, lateral pressure, 
and mechanical traction. Direct pressure may be sufficient to cause 
reduction in buckling or green-stick fractures, or in oblique fractures 
with little displacement. It may be applied for a short time to cause 
reduction follow^ed by fixation in an external splint, or it may be applied 
continuously over a period of time by means of pads. 

The surgeon must make use of general pathological bone knowledge 
and experience in setting fractures. When the roentgenogram is to be 
had it is of assistance, but practically the adept makes out the type 
and extent of the displacement even in those bones which are covered 
by thick, soft parts. Delicate manipulation, close observation, and 
measurements indicate the type of displacement — whether it is 
shortening, angular, or rotatory. It is impossible to expect anatomical 
reposition in any great percentage of cases reduced blindly, even 
though anatomical knowledge of the highest grade be used. Even 
if difficult to obtain, a roentgenogram should be used after the best 
possible reduction has been performed. Glaring faults are often 
revealed. 

The Supreme Court of Washington has recently decided a case^ 
abstracted in the Journal of the American Medical Association.^ 
The plaintiff w^as injured in a coasting accident which fractured her 
leg above the ankle, and also fractured the femur above the knee. 
There was an open wound which became infected. The attending 
physician did not recognize the femur fracture until a roentgenogram 
was made two weeks after the leg fracture was set and put in a plaster 
cast. She was awarded $7305 damages. On appeal it was argued 
that the trial court had erred in allowing evidence to be received tending 
to show^ that the defendant was negligent because a roentgenogram was 
not taken sooner after the accident, etc. The Supreme Court held 
that this w^as all right but that because the surgeon cannot be held 
to answer for the suffering caused by the original injury but only 
for the suffering caused by his own neglect, the damages awarded 

1 Deutsch. med. Wchnschr., 1913, p. 17. 

2 Zentralbl.. f. die Gesamte Chir. u. ihre Grenzgeb., 1913, Bd. i, 175, and Zentralbl. f. 
Chir., 1913, p. 763. 

3 Zentralbl. f. Chir., 1911, p. 1337. 

4 Cranford vs. O'Shoa (Wash.) 145, Pac. R., 579. ^ May 8, 1915, Ixiv, 1606. 



IMMEDIATE TREATMENT 105 

were excessive, and $2000 was cut off the amount. This remission 
was in accordance with the hiw's demand tliat the phiintiff' bear her 
share of the misfortune which chance liad brouglit uj)()n the ])arties. 
If the hmb is corrected to a jiosition of normal axis, and the principal 
points of displacement are straightened in a manner satisfactory to 
the eye and palpating fingers, the surgeon may anticipate a favorable 
outcome. Overcoming of the effect of gravity and of contracted 
muscles which cause most of the displacement, can be accomplished 
through the relaxation of certain groups by means of flexion, and 
advantage must be taken of these positions while the general axis is 
maintained. Sir Astley Cooper and others taught the value of maximal 
relaxation of a limb in semiflexion, and this position in treatment has 
lately been revived by Zuppinger. The proper support of the limb 
in a suitable fixation dressing is a part of this treatment, but some 
cases which are treated intelligently and give no outward evidence of 
being unusual, fail to respond in the normal way, and complications 
ensue. This course of events is beyond the skill or knowledge of the 
surgeon to prognosticate, and such results are as common in faithfully 
attended instances as in the neglected ones. Undoubtedly the causes 
of non-union, for example, lie within the patient in the majority of 
cases and are not much influenced by external treatment in the period 
demanded for ordinary bone union. 

The limitations of treatment and the prognosis of different fractures 
are indicated under the heading of each bone. 

Traction. — Traction may be divided into (a) immediate traction by 
a direct powerful pull and (b) prolonged traction. 

(a) Immediate Traction. — Immediate traction may be applied man- 
ually by the surgeon and his assistants pulling and counter-pulling, 
grasping the limb in their hands. Harness or a bandage may be 
arranged on the extremity of a limb whereby the surgeon may apply 
his body weight for securing traction. In the reduction of fractures 
about joints such as the malleolar fractures at the ankle, stresses and 
pulls are exerted by traction on muscles and ligaments. This principle 
is particularly useful in epiphyseal separations. The best method of 
applying traction is by mechanical means. There are two general 
forms of mechanical extension in use. Without this form of extension 
many fractures cannot be satisfactorily reduced; wdth it many cases 
which seem to lie wholly within the operative class wall be removed to 
the non-operative. With mechanical extension applied for a few 
moments more direct force of traction can be applied on the fracture 
than several assistants can furnish by manual pull. I recall seeing 
Dr. Joseph Blake at the Presbyterian Hospital in New York some 
years ago. He with six assistants was trying to lengthen a leg which 
had a fractured femur. An open operation had been performed, and 
the bone ends were freed, but after a half-hour of tugging, which 
disarranged the operative field completely, I doubt if they had gained 
a quarter of an inch in length. Extension applied by canvas or other 
swathes directly on the end of open fragments (Edwin Martin) or 



106 



TREATMENT OF FRACTURES 



Gerster's tiiriihuckle^(see Operative Treatment) etc.; are not needed 
when one has mechanical extension. 




.Ti.»;N VS. - ^^„^^,^..,„,,^^^^j,.„„.,,s.^ ■::^'''j':vv"is^^'s;: 




^ 



]C^^ 




Fig. 24. — Table ready to receive a patient, foot brackets attached and in position. 

The portable apparatus of Ridlon answers nearly all purposes for 
forcible mechanical leg extension. I use it in operating on cases at a 
distance. Through use of t sufficient force can be exerted to pull 
out a strong thigh or leg until the desired length is obtained. It 




z'-'--x,!:^^' r<£,'.'^«"^'S K'S'ia^^'' ^i-vzit^ 



Fig. 25. — The foot portion of the table is dropped so that the operator can apply leg or 
body encasement easily while traction is maintained. 



needs tw^o tables set close together and an assistant to hold the extended 
leg and tighten the traction. This holding is tiresome, expecially 
when body casts are applied. 



IMMEDIATE TREATMENT 



107 



Another extension or traction apparatns is the Hawley fracture 
table, which I have been using continuously for some time. This 
table is not portable, but in addition to offering mechanical traction 




^^iiimm 



Fig. 26. — Patient supported on table ready for application of body and leg encase- 
ment. Note the pelvic support, the bandage support of the thighs and the attachment 
of the feet for traction. 

for leg and thigh fractures and their operative or non-operative fixa- 
tion, it can be used for applying orthopedic plaster casts or dressings 




on arms and shoulders. It also permits traction on legs in part flexion 
and saves time in application of casts, and reduces the number of 
assistants necessary (Figs. 24 to .32). 



108 



TREATMENT OF FRACTURES 



Wliilo traction is in force the surgeon can correct lateral displacement 
hy direct pressure. In oblique or transverse serrated fractures ad- 
\ antage may be taken of rough edges or points which interlock and 




Fig, 28. — Method of applying traction and counter-traction with extension before 

applying plaster. 

hold reduction. Penetration of muscles by sharp fragments, a common 
occurrence in the lower part of the femur and the upper part of the 




Fig. 20. — Detail of cuff applied about the ankle. This is used to take up the force of 

traction. 



humerus, cannot be reduced by direct traction. The bone fragment 
must be disengaged from the muscle. This is done by manipulation 
which seeks to relax fully the muscles concerned. In the thigh, the 



IMMEDIATE TREATMENT 



109 



hip and knee are flexed to relax the quadriceps muscle and pull it down 
over the sharp point of the upper fragment. ^Yhen the bone is freed 




Fig. 30. — Foot applied to rest and traction tightened. After the plaster hardens the 
metal foot piece is lifted out of position. 

the distal portion of the limb is swung out into line with the upper 
part, and traction is started to lengthen the contraction and bring 




Fu.. .31. — Method of using the fal)lc to ;ii>pl\ .inn i r.Kt ion. 

the fractured surfaces into aj)positioii. If niaiiipnhitioii fails, o])cii 
operation is indicated. 



no TREATMENT OF FRACTURES 

(b) Prolonged Traction. — Prolonged traction is applied by non- 
operative and by operative means. The non-operative types are 
Buck's Extension, or adhesive extensions, which depend on gravity 
or weights hung on a pulley. Examples of these are the Hodgen 
splint for the leg, the Thomas splints and harness extension, as for 
fracture of the spine, and plaster casts with provision for extension 
on imbedded metal rods (Hackenbruch's). Bardenheuer and the 
Cologne school have worked out an elaborate system of adhesive- 
plaster extension for fractures. 

Grune, from Bardenheuer's clinic,^ has reported 41 cases of fracture 
of the femoral neck treated by extension, in only 3 of which was 



Fig. 32. — Body and arm plaster encasement applied while the patient lay on the table. 

the shortening equal to J to 1 cm. This treatment requires much 
care in its course. 

The operative tractions are Codivilla's and Steinmann's nail exten- 
sion and Ransohoff 's ice-tong modification. (See Operative Treatment 
for Fractures of the Femur.) 

Traction which is continued causes stretching of joint ligaments 
and fascial sheaths as well as of the contracted muscles. Which 
type of structure yields first is difficult to say, but clinically we know 
that muscles gradually tire out and elongate so that length of a limb 
can be gained after a long period of time. It is also a question as to 
how much reposition of bone is gained by prolonged traction. I 
believe that the ordinary Buck's extension, used as it frequently is 

« Deut. Ztschr. f. Chir., 1913, p. 81. 



IMMEDIATE TREATMENT 111 

with the leg bound to a Liston spHnt or lying in a fracture box or on 
the bed, has little real extension pull. For that reason the Hodgen 
suspended splint which relies on gravity for a steady pull is much 
better in thigh fractures. Ordinarily the weight hung on to a Buck's 
extension is too small, and the leg friction on the bed surface or the 
mal-application of the pulleys and ropes cuts down the real force 
exerted. A simple universal extension apparatus has been devised 
by Swenson^ which obviates these difficulties. 

The use of Buck's extension is so universal with the profession that 
its faults compared with the suspension principle of the neglected 
Hodgen splint have been overlooked. Brady ^ has called attention 
to the advantages of this type of suspension in fracture of the femur. 
Hodgen's splint (see Fig. 33) offers an unremitting extension assured 
by the elasticity in the arrangement of the extensive force, whereas 
the Buck's extension is a dead pull of an unestimated force because of 
the unknown factor of friction. With the Buck dressing two fixed 
points are necessary, one at the patient's pelvis and the other at the 
pulley, but the Hodgen suspension requires but one fixed point, the 
limb's ovm. weight taking the place of the pulling ^weights in Buck's. 
There are other advantages which can be credited to the Hodgen 
extension: the limb lies in physiological flexion in accordance with 
Zuppinger's teaching. The hamstring and psoas muscles are relaxed 
and do not obstruct reduction. The pull on the lower fragment can be 
accurately estimated by means of a spring scale included in the 
suspending cord. The patient can turn in bed, sit up and assist himself 
in many ways without changing the position of fragments, relaxing 
the tension, or jerking the limb, because the motions occur at the hip- 
joint and not at the fracture site. Although the patient's movements 
while in Buck's extension seem to have no untoward effect on bone 
healing, they are painful and tend to permit recurrence of the deformity. 

Hodgen Splint Construction. — The frame is made of iron wire the 
thickeness of a lead-pencil, its length being from 32 to 38 inches 
measured from the perineum to a point 4 inches beyond the sole. 
The base breadth is 4 inches with a little lateral spreading at the 
malleoli. A picture of Brady's modification is given. He solders six 
upright rings on the frame and at the base fixes two upright wire 
posts or loops 2 inches high through which the extension straps 
pass. At the free end is a wire wicket which locks on after application 
to prevent the splint from spreading under the weight of the limb. 
The hammock in which the leg lies is made of heavy muslin in which 
are cut buttonholes corresponding to the six rings and the two upright 
wire loops. The hammock is loose enough to allow for slack which 
gives room for the calf and heel. It is pinned to the frame with safety 
pins. From each supporting ring a waxed twine is attached and run 
to a common supporting point above the foot, where they are looped 
over the hook of the spring scale. Each supporting twine is fastened 

• Surg., Gynec. and Obst.. Augu.st, 1914, p. 114, 
2 Internat. Clin., Philadelphia, 1915, 25 S. i, 191. 



112 



TREATMENT OF FRACTURES 



hy moans of a tent block. To the handle of the sprmg scale a piece 
of sash cord is fastened, and this cord is run up over a pulley in the 
ceiling and back, fastened by being knotted in another tent block. 

Method of Application of Ilodgeiis Extension. — Two-inch adhesive 
plaster is applied to the shaved leg as for Buck's extension, except 
that two separate pieces are used instead of a long loop. Beyond 




4 



Fig. 33. — Illustration of the Hodgon splint for fracture of the thigh. Adapted from 
International Clinics, 1915, 25th series, vol. i. Note the bare splint, the method of apply- 
ing extension at the ankle and the completed and suspended spHnt holding leg. 



each malleolus is left free a six-inch extension, which is doubled back 
on itself to make a three-inch tab with no adhesive surface exposed. 
The up])er end of the plaster strips lies at a level just below the fracture 
site. On to each adhesive tab is pinned a strip of muslin a foot and 
a half long. After this preparation an assistant lifts and moderately 
extends the limb at the ankle, the frame is slipped under with the 



IMMEDIATE TREATMENT 113 

free end at the perineum and the wicket is locked in place. The 
two muslin strips at the ankle are drawn through the wire loops at the 
end of the splint and tied. Leg contour is allowed for by adjusting 
the pins which hold the muslin hammock, the waxed cords are attached 
and adjusted by the tent blocks, and the limb is lifted just free from the 
bed. The spring scale indicates the weight of the limb in this condition. 
The leg is then hauled up free from the bed and the frame is bent about 
20 degrees at the knee, after which the cords are again adjusted until 
all pull smoothly, with the buttock raised enough so that the hand 
can sweep freely beneath it. With this corrected position the spring 
scale will read 5 to 8 pounds more weight than the simple weight of the 
limb, the extra weight representing the actual pull on the leg. The 
bend in the frame is meant to allow for the normal physiological 
semiflexion of the leg. Abduction can be obtained by locating the 
pulley plane to one side, or by moving the bed. With young 
patients it is necessary to place a small sand-bag on the frame to give 
additional weight for overcoming the shortening, because the leg's 
weight is insufficient in itself to overpower the resistance of its strong 
muscles. A similar increase of pull is given by the moving of the bed 
farther away from the pulley. With obese patients, when the leg is 
too heavy and gives too much pull by its own weight, the bed is drawn 
more directly under the pulley to lessen the stress. 

After-treatment. — Pressure on the heel must be guarded against, 
and the hammock can be readjusted to obtain comfort. No sand-bags 
or coaptation splints are needed. A minimum excess of four pounds 
over the limb weight is required on the spring scale. Brady states that 
the limb should rest f below and | above the level of the arm, and that 
the adhesive must pull perfectly straight. Inversion or e version are 
gradually overcome as the muscles tire, so that by the time the two 
legs are of equal length e version has disappeared. In the early stage 
of treatment marked eversion can be corrected through tightening of 
the outer pair of supporting cords. The thigh muscles, helped by the 
uninterrupted traction, act as a splint, and within eight to fourteen 
days the leg has straightened out and reached its full length. When this 
condition is established all dressings are removed, the leg is massaged 
and later put in a light circular cast or moulded splint, and crutches 
are furnished. Fractures of the neck should have at least six weeks' 
extension, followed by a cast and ambulatory treatment. 

The Thomas Splint. — The Thomas splint rigged for extension from 
the bottom of the frame with its counter-extension by the padded ring 
around the thigh and buttock, offers real extension. Mr. Robert 
Jones related to me some time ago a case of open fracture of the 
lower end of the femur in which the lower fragment was flexed by the 
calf muscles and came to lie sticking out of the wound. Treatment 
was started in a Thomas's splint with extension and counter-extension, 
and he assured me that his house surgeon was able to notice from day 
to day the final complete alignment of this flexed lower fragment with 
the rest of the shaft. 



k 



114 TREATMENT OF FRACTURES 

The development of the distraction of nail extension is interesting. 
In 1903 Codivilla first applied a cast to a fractured leg from the toes 
to the pelvis. The next day he cut the cast circularly, dividing it 
about the middle of the thigh. By means of strong traction the 
severed surfaces of the cast were separated, and the space created 
was filled in with fresh plaster of Paris, traction being maintained 
until setting. This procedure could be repeated. The method was 
abandoned because decubitus sore developed about the tuber ischii 
and the dorsum of the foot. To avoid these pressure ulcers Codivilla 
left the foot and ankle free and put two lateral irons into the lower 
end of the cast. The free ends of the irons ran down beside the ankle 
and were fitted by means of holes over a nail driven through the os 
calcis. Pads were applied over the ischium, and decubitus was avoided. 
Steinmann, in 1907, discarded the cast altogether and applied traction 
directly to the nail ends passing through the os calcis. 

In von Eiselsberg's clinic in 1901 Kafer, in putting a cast on a leg, 
incorporated a turnbuckle on either side. The cast was cut and the 
halves distracted by turning up the turnbuckles. Hackenbruch 
improved this method by putting a ball-and-socket joint at either end 
of the turnbuckle where it joined onto the imbedded plate. By dis- 
traction, shortening in the leg was overcome inside of forty-eight 
hours; then the four ball-and-socket joints were cautiously loosened, 
and any lateral displacement was corrected. The reduction was 
checked by roentgenograms, and when a satisfactory adjustment was 
reached all points were firmly fastened and the patient was allowed to 
walk on the leg thus held in perfect position.^ Patterson's method^ 
is the same. Gerster^ has adopted Steinmann's nail extension as a 
part of a splint for maintaining extension during transportation. To 
avoid the pressure on the ischium he used an upper padded ring made 
in two halves hinged behind and locking in front. The splint was 
composed of long bars of hard wood, which do not interfere with 
roentgenograms, and the lower end was formed by a stirrup with 
slotted bars permitting adjustment by thumb-screws. Tongs were 
applied to the nail, and a cross bar held them up, while a rope attached 
them to the distal end of the splint. 

Fixation. — Fixation purposes to maintain the reduction obtained 
and to prevent subsequent displacement of the fragments. To 
accomplish this result fixation must overcome muscular contraction, 
ligamentous pull and gravity, should relieve pain, and should furnish 
security from slight external disturbances and subjective movements. 
Some of these indications are met by the traction and reduction 
methods which may also be considered fixation treatment. There are 
also certain accessory procedures which are used as routine in fracture 
treatment. In spinal injuries we always employ air or water beds 

' Hackenbruch's references, Ztschr. f. ilrztl. Fortbild., 1913, p. 28; Zentralbl. f. Chir., 
1913, p. 605; Deutsch. Ztschr. f. Chir., Bd. cxxii, 464. 

2 Am. Jour. Orthop. Surg., 1913, p. 649. 

3 Am Jour. Surj?., xxviii. No. 31; and Am. Jour. Med. Sci., August, 1913, p. 157. 



IMMEDIATE TREATMENT 115 

to give uniform pressure on the parts compressed by long periods of 
recumbency, and in leg fractures which are kept in bed, a fracture 
bed is made. A fracture bed consists of one or more flat boards, of 
lengths equal to the bed Avidth, passed across the long axis beneath 
the mattress to furnish a flat resisting surface for the splint to lie on. 
These boards prevent sagging and bending of the bed surface. 

Regardless of the character of dressing used on a limb after fracture 
the most important feature in the first few days is the condition of 
the circulation in the part. In order to guard against interference with 
circulation no splint should be applied tightly at any time, especially 
soon after an injury when the swelling which follows all fractures 
has not reached a maximum. Slight external pressure, additional 
to the internal pressure in the limb, may completely interfere with 
blood supply, resulting in local pressure necrosis or ischemia of the 
whole limb with subsequent contracture. This danger is avoided by 
the employment of loose cotton padding or sheet wadding about the 
limb. Xo limb should be bandaged by means of a roller bandage 
beneath a splint. Fingers and toes should be exposed and watched 
for evidence of imperfect circulation. It is neither wise nor customary 
to apply circular casts or tightly fitting splints to a fresh fracture 
even if it has little displacement, because a mild local fracture reaction 
of extravasation and swelling is expected. Fractures of the arms and 
legs are best cared for by complete rest in bed at first, in temporary 
splints, until swelling has disappeared. The probable formation of 
blebs, with the necessity for their aseptic evacuation, and the care 
of abrasions and small cuts in the skin also militate against early 
permanent dressing fixation, but not against early reduction if it can 
be held. If the condition of a part warrants treatment in a permanent 
dressing before these skin lesions are completely healed, they can be 
allowed for by suitable openings. 

Types of Fixation Dressings and Splints. — Coaptation splints are 
composed of wood, cardboard, and leather, in narrow strips. Malleable 
iron, zinc strips, and aluminum, are also used. These splints are applied 
to limbs in fracture of the shafts of bone and may be used alone or in 
conjunction with extension or other forms of dressing. They are 
laid on in series, like a bundle of faggots, encircling the limb at the 
fracture site, being bound on by bandage or tape. Strips of wood 
not much larger than the common wooden tongue depressors are 
excellent coaptation splints. They can be sewed into muslin bands 
to make a sheet. An amount necessary to encircle the part is cut oft*. 
The malleable iron splints can be moulded bj' the surgeon's hands. 
Robert Jones prepares them in many sizes for adult and children's 
use. They are shellacked and padded on one surface with a coarse 
felt. Ordinarily coaptation spHnts are not applied on a bare skin; 
cotton or sheet wadding is put beneath them. 

Wooden splints are u.sed con.stantly. Any piece of wood from 
the size of a small wooden tongue depressor for a finger to a 2 x 4 
scantling is used to immobilize broken bones. They are applied 



no TREATMENT OF FRACTURES 

laterally or posteriorly or in combination as on each side of the forearm. 
The wood itself is padded over with cotton wadding bandaged on. The 
limb is further protected by cotton or wadding at bony points and 
(le})ressions. This padding is placed around the joints, not over them; 
then the padded splint is bound against the limb by bandages or 
adhesive plaster. 

Fracture boxes are wooden boxes inclosed on three sides and are 
used as temporary splints. Some have sides which are hinged and 
held by buttons or hooks, so that the lateral aspect of a leg can be 
inspected by the opening of one side, without displacement of the 
entire limb. These boxes are partly filled with cotton, and the leg 
is slipped into them and arranged in a comfortable position, with 
excess padding beneath the heel and knee. The foot is straightened 
and is held by a turn of bandage, a wad of cotton, or a small narrow 
sand-bag. This splint permits the application of an ice-bag and is 
often used for cases of great swelling and ecchymoses with bleb forma- 
tion until permanent reduction and fixation are safe. Shallow moulded 
metal gutters with a right angle foot-piece have partly taken the place 
of fracture boxes because they are lighter and occupy less space. 
They will never completely usurp the place of the fracture box, because 
the box is easily and cheaply made anywhere and a leg can be laid in it 
on a soft cushion, whereas the leg must be bandaged to the metal 
splint and danger of pressure is thereby incurred. The box has also 
greater stability of position. 

Other wooden splints used are double inclined planes which are 
adjustable to different angles and railroad splints, or the Volkmann 
sliding splint. These hold the leg laterally in axis alignment and permit 
the application of elastic or weight extension. A good railroad splint 
which provides for elevation of the leg, knee flexion, and application 
of extension, is a very valuable dressing for hospital use. It has great 
stability. Wire splints of two kinds are serviceable. Coarse-meshed 
galvanized wire is often used as an outside splint around dressings 
after bone operations. It is light, easily removed, and stiff enough 
to prevent dislocation of fractured ends. The second class of wire 
splints is composed of wire gutters, coaptation, and other extensive 
leg splints. Some of these are adjustable for different angulation of a 
limb, or for various degrees of abduction and adduction of the foot. 
They come in different sizes and can be moulded by the surgeon's 
hands to fit. Their advantage is lightness, ventilation, cleanliness, 
and durability. They are bound on the padded limb by bandage or 
adhesive plaster. Page^ described aluminum skeleton splints for both 
the leg and arm. The leg splint is like the Hodgen and the arm splint 
is a lateral skeleton which permits some extension on the forearm. 

Suspended splints are either anterior or posterior. The Hodgen's 
splint, which is posterior, has been described. The best known anterior 
splint is that of Nathan Smith. This is made of two parallel iron rods 

1 Brit. Med. Jour., May 15', 1915, No. 2837. 



IMMEDIATE TREATMENT 117 

joined by three or four curved cross rods. The spUnt is bent in the 
form of semiflexion of the leg and the leg is attached to it by bandaging 
or straps. The leg is swung up by rope to a pulley. It is used in 
fractures of the femur. Sometimes such a device is imbedded in the 
anterior surface of a plaster encasement of the leg. Parts are cut 
out of the plaster after it hardens to permit dressing of an open wound 
or ventilation. This splint is little used now, other methods of 
suspension or extension taking its place. 

The two most important splints for extension and immobilization 
of the leg are the Thomas and the Englemann splints. The Thomas 
splint has been described previously. It is strong, durable, and very 
efficient, especially when combined with elastic extension at its lower 
end by Buck's adhesive method. The Englemann splint is really a 
modification of the Thomas. It is composed of two metal strips with 
a ring at the top to fit over the thigh and against the tuber ischii. The 
lower end is attached to a nail driven through the sole of the shoe, 
and the whole is adjustable to extension by means of the sliding 
character of the side rods, which can be fastened by thumb-screws. 
It is not as valuable a splint as the Thomas, which can be combined 
with a body portion to give abduction of one or both limbs, and on 
which children can be placed and moved about at ease. (See Ambula- 
tory Splints.) 

Plaster of Paris.- — Plaster is used in two forms, as moulded splints 
and as plaster encasements. Many surgeons use it exclusively in 
treatment of fractures, both as temporary and permanent dressings. 
Moulded splints are seldom made of leather. Plaster is cheaper and 
can be moulded to fit any form or angle. Moulded splints are made 
either by using coarse meshed gauze pads cut out in the required shape 
and soaked in a plaster cream, or by direct application of plaster 
bandage to a limb without circular encasement. These wet plaster 
masses are bound on the padded part by means of an outside bandage, 
and the limb is held in the position required until the plaster has set. 
After hardening the splint can be quickly removed if pressure symptoms 
appear. The best method is to take the exact measurement of length 
of splint desired, and use broad plaster bandages. They are run out 
on a glass or slightly greased surface layer after layer in the desired 
dimensions, and when the mass is thick enough it is applied over the 
limb and bound on to set. This method saves plaster and time, 
especially when the patient is under anesthesia, or after operative 
procedure. One assistant can be laying out the moulded splint while 
the surgeon is dressing and padding the wound or making a reduc- 
tion. Moulded splints may be anterior, lateral, or posterior, and one 
or two may be applied on the same limb. (See picture of moulded 
splint used in ankle fractures.) 

Plaster encasement or a cast as it is called, is applied by turns of 
wet plaster bandages, weak points being strengthened by longitudinal 
folds. This type of dressing should never be applied to a fresh fracture 
even when the displacement is nil. It is impossible to foresee how 



lis TREATMENT OF FRACTURES 

nmcli swelling, or what complications involving the skin surface, as 
blebs or infections, or what circulatory changes will follow. Small cuts 
or abrasions on the skin may become the source of serious infections 
l)()ssibly gangrenous in type, and if the limb is enclosed in a solid plaster 
mass, no direct evidence of the progress of these conditions can be had. 
Circular encasements should be applied only to cases in which the 
primary swelling has disappeared and the skin condition is satisfactory. 
It is the best practice to imbed in each cast a Gigli saw, so that it can 
be split longitudinally as soon as it hardens. This split permits some 
swelling within its confines and prepares it for immediate removal 
in case of obstruction to the circulation, or pain. If these measures 
are considered necessary by surgeons in hospital practice where patients 
are under constant surveillance, can any one doubt the necessity of this 
step under other conditions where the doctor does not see the patient 
for hours or days after the dressing is applied. 

The technic of application is simple. The limb is carefully sponged 
off with alcohol, and small abrasions are touched with tincture of iodine 
and covered with sterile gauze. Cotton padding or wadding is applied 
loosely over the skin surface, the formation of wrinkles being avoided. 
No bandages are applied beneath casts. Bony prominences can be 
protected by extra cotton applied around them. The plaster bandages 
are placed end up in warm water, which must be deep enough to cover 
them entirely. This position of the bandage allows the water to 
permeate it quickly and favors a rapid driving out of the air bubbles 
through the open bandage end. When removed from the water they are 
not wrung or milked to force out all the plaster cream they contain 
but are given one squeeze by a firmly grasping hand. If quick setting 
is desired salt or powdered alum may be added to the water. 

The bandages are applied smoothly and are never reversed. 
Longitudinal folds are valuable for strengthening as suggested. The 
cotton padding is left long beyond the area of plaster application and 
as the encasement is finished this extra wadding is turned back and 
held by a turn or two of the plaster bandage. This gives a finished 
effect and a soft non-irritating edge. To smooth the surface, plaster 
cream may be applied, or the surface may be rubbed off with a gauze 
sponge soaked in alcohol. Most surgeons wear rubber gloves in this 
work to protect their hands. 

Bands of metal or wood may be imbedded in the plaster to strengthen 
it. The casts may be interrupted, connected by bowed pieces of iron 
which are imbedded in the plaster above and below an exposed area. 
Windows are often cut out over areas of abrasion or wounds. These 
should be removed by a sharp short-bladed knife before the plaster has 
completely set. When body casts are applied it is advisable to have a 
Bradford frame ready on which to place the patient. 

Ambulatory Splints. — Ambulatory treatment of fractures has come 
to mean two different things. The patient may be put in a permanent 
dressing and allowed to be up and around even if a leg is involved. 
He uses crutches without bearing weight on the fracture and is con- 



IMMEDIATE TREATMENT 119 

sidered to be ambulatory. Ambulatory treatment really means 
that in fracture of the lower limb some rigid splint is applied which 
permits the patient to walk with crutch or cane at once, using the 
injured leg to bear weight. It is asserted of this type of treatment 
that it favors bony union, it shortens time of disability and hospital 
stay, it lessens danger of hypostatic lung congestion and other compli- 
cations. 

Ambulatory splints are made of plaster of Paris or metal or a 
combination of both. A solid plaster encasement which holds the 
fracture in reduction can be strengthened at the foot end by the 
imbedding of an iron stirrup. The shoe of the well foot is raised to a 
corresponding height by an extra sole, and the patient is permitted 
to walk with crutches. If an iron projection is not used, the plaster 
quickly wears away and breaks. Other ambulatory splints are made 
of metal padded with leather and pneumatic bands. These embrace 
the trunk and the injured limb and provide for extension. In cases 
of imperative ambulatory treatment or non-union which can be 
stimulated to repair by the irritation of walking, these splints are 
valuable. They are expensive and cumbersome. Some dealers rent 
them for the period of immobilization demanded. 

Dollinger has been an advocate of ambulatory treatment since 
1911. Since that time many different types of splints have appeared. 
All take fixed bony points such as the tuberosity of the ischium and 
the femoral condyles for pressure. They are all thoroughly padded. 
Patients are encouraged to walk from the first. Tobben^ has devised 
an ambulatory dressing with extension. He used a firm felt anklet 
with eyelets at the lower margin. This is fitted snugly over the malleoli 
and is cut open behind to avoid pressure on the calcaneus tendon. 
A plaster cast is applied from just below the knee to within two inches 
of the ankle. An iron stirrup which extends well below the heel 
is incorporated in the plaster cast. One inch proximal to the stirrup 
cross piece is a second iron cross bar, which has a thumb-screw in its 
center. From the eyelets of the anklet strong laces extend to the 
thumb-screw, which when tightened caused traction on the leg. 
Jaboulay has a similar apparatus in which traction is made on a shoe 
plate instead of an anklet.^ Giaquinta-^ advocates ambulant treatment 
with extension. The ambulant treatment of Hackenbruch^ is applied 
in fractures of both bones of the leg. A plaster encasement is put on 
the leg from below the knee to the ankle. The areas around the 
patella and knee and the ankle are very thickly padded. The day 
after the application, the cast is cut over the site of fracture and 
Hackenbruch's clamps are inserted. By means of these adjustable 
clamps powerful extension is applied, which is increased daily until a 
satisfactory position is reached, whereupon the clamps are set and the 
patient is allowed to walk. The knee is nearly always quite movable, 
the ankle has slight motion, and the foot is free. Treatment with 

» Zentralbl. f. Chir., 1913. p. 996. 2 Patel, Progres mcd., 1913, p. 286. 

» Gaz. degli osp. e delle Chir., 1913, p. 13. " Lancet, Marrh 14, 1914, p. 744. 



120 TREATMENT OF FRACTURES 

this extension obtains complete lengthening in a week, according to 
its inventor, and the patient becomes ambulatory in the second week, 
the cast being left on four weeks or more. 

Massage and Allied Treatment. — Massage and passive motion 
are decidedly diil'erent measures and have different effects on fracture 
results. There is almost universal agreement that nothing but good 
results follow early and gentle massage after fracture. Lucas-Cham- 
pionniere is the most extreme advocate of massage, which he combines 
with movements and passive motions of the neighboring joints 
throughout the whole course of repair of fracture. The massage should 
not include passive motion of the fracture site. When the massage is 
given, it is given to relieve swelling and edema, to promote freer 
circulation and consequently reduce pain, and to hasten repair of 
bone. It is done with the finger tips alone in recent fracture, the oper- 
ator rubbing in gentle steady strokes always toward the body. Early 
passive motion on the other hand is distinctly harmful. Passive 
movements which produce a rebellious reaction of pain and swelling 
in the fracture site or joint are pernicious. They cause disturbance 
of the uniting bone fragments, they lead to fresh plastic effusion, 
and result in exc'essive callus and connective-tissue formation. The 
ultimate results are increased involvement of the soft parts about the 
fi*acture, or an unnecessary stiffness of joints involved. The elbow- 
joint is the one most frequently harmed by passive movements. 
(See Treatment of Elbow Fractures.) These injuries should not be 
given movement, except at the one time when reduction is performed. 
The joint should be settled in the position necessary for a perfect 
reduction of fragments and then should be left undisturbed, until 
the surgeon is satisfied that bone union will not be harmed by move- 
ment. This statement can be applied to all joint fractures equally 
well. In fractures of the anatomical neck of the humerus light massage 
may be practised from the time of injury, but no passive movement 
should be permitted within two or three weeks, and then all motions 
should be below the threshold of pain production. If this rule is 
insisted on, motion usually becomes very satisfactory after six weeks. 
Hitzrot^ gave end-results in 139 cases of upper humerus fractures 
treated by massage and movements every other day ten days after 
injury, with all splints removed after the third week. All but 2 of 
these cases lost hyperabduction of 5 per cent, or more, the hyper- 
abduction being measured by the scapular movement from the mid- 
line of the back compared to the normal side. 

Forcible passive movement should never be started after fracture 
near or into a joint in the hope of restoring normal movement. When 
this is repeatedly performed with painful results or under anesthesia 
it leads to a stiffer condition in the joint. Even active motion must 
be inhibited when it causes the slightest pain. 

After the removal of splints or permanent dressings and change 

1 Ann. Surg.. Iv, 348. 



IMMEDIATE TREATMENT 121 

of position by the patient, there is nsually some acnte swelHng and 
edema of the peripheral part of the Hmb. For this condition a shghtly 
deeper massage may be given, bnt the patient mnst be guarded against 
sudden movements which throw extra stress on the recently healed 
bone. This secondary massage promotes earlier return of function 
and lessens muscular atrophy. Attention is directed to the cases of 
fracture of the tibia at the site of removal of bone splints. One 
occurred nine months after removal of the splint from the tibial 
crest when the patient put sudden excess strain on the leg in attempt- 
ing to board a street car. These legs had been partly weakened by 
the removal of the bone peg. Gillette has inveighed against passive 
motion in injured joints^ recalling the fact that human joints exhibit 
the highest form of mechanical pulley and leverage action. They 
are unlike manufactured mechanical joints, in that they possess 
an ability for self -repair and lubrication and do not wear out. After 
injury or fracture into them, mechanical obstruction or intercurrent 
disease must be overcome before motion is attempted by force or 
otherwise. 

Treatment of fracture must primarily aim at immobilization of 
bone fragments, but not of all muscles and tendons in the vicinity, 
if they can be used actively ivithout pain or can be delicately massaged. 
In vrvist and arm fracture constant early finger movements are urged 
unless pain results. After the fourth decade in life there is greater 
tendency than earlier to edema, adhesions, osteo-arthritis and throm- 
bosis after fracture, and consequently the surgeon's efforts must be 
directed toward an early anatomical reduction. This is more important 
in the leg than the upper extremity, and more disability in walking 
arises from stiff and subankylosed ankles and improper leg axis than 
from shortening. 

Other accessory treatment after fracture consists in hydrotherapy 
of hot and cold baths, electricity, and baking, all looking toward 
improvement of circulation and restoration of muscle tone. Persistent 
active muscle movement is the best adjunct. 

The Committee of the British ]Medical Association in 1912 made a 
painstaking study of 2940 cases of fracture, of which 208 were operated 
cases. 

They desired to weigh the value of operative and non-operative 
treatment. The operated cases were selected from the clinics of those 
surgeons who were skilled in and best equipped for this work, and the 
non-operated cases were taken from the services of a representative 
list of general practitioners. The good results asserted in operated 
cases were 79 per cent, as compared with 70 per cent, in non- operated. 
This report, as well as that of the Committee of the American Surgical 
Association in 1913, is referred to later under the heading of Operative 
Treatment. Estes^ has rearranged the conclusions of the American 
committee: 

' .lour. Am. Med. Assn., October 17, 1914. 
2 Am. .Jour. Surg., xxviii, No. 1. 



122 TREATMENT OF FRACTURES 

1. Although t'uiu'tioiial result may be good with indifferent 
anatomical result, the most certain way to obtain good functional 
result is to secure good anatomical result. 

2. In nearly all age groups operated cases show a higher percentage 
of good results than non-operated cases. 

3. No method which does not promise good anatomical result can 
be chosen. 

4. The operation should be performed as soon after fracture as is 
consistent with best results. 

5. The mortality of operative interference is so small that it has 
little weight. 

(). Operative interference requires special skill, etc. 

7. Because many surgeons and practitioners are unable to avail 
themselves of the operative methods, the non-operative procedures 
are likely to remain more safe and serviceable for some time. 

Some of the points to which I have called attention previously 
should be made more emphatic. The roentgenogram should be used 
as an accessory whenever possible, and the dried plate should be 
studied and its information added to the clinical findings and the 
surgeon's own experience in decision upon treatment. Complete 
circular encasements of plaster should be rarely used. Splints which 
are easily removed and arranged are much safer. Painful passive and 
active movements should be prohibited, but gentle massage and a 
shortened period of confinement in immobilizing dressings are in the 
trend of modern treatment. The value of the radical teaching of 
Lucas-Championniere's mobilization and of Bardenheuer's extension 
is doubtful. A median course must be adopted. What is really aimed 
at is a method of treatment which will ensure perfect anatomical 
restoration of form and function. Such a security of mechanical 
fixation is sought in those cases subjected to operation that after 
operation the bone may be stronger than before the fracture, and the 
fixation may last indefinitely. It must not depend on the frictional 
grip of nails or screws in the bone.^ 

The ideals of treatment may not be unattainable by those especially 
trained in this field of work. To further that possible attainment 
treatment of fractures in any large hospital should be assigned to 
the men who make special study of the pathology and end-results. 

1 Hey-Groves, Lancet, February 14 and 21, 1914; Warren, Lancet, July, 1909. 



CHAPTER VI. 

OPERATIVE TREAT]\IENT OF OPEN AND CLOSED 
FRACTURES. 

Diverse opinion exists in regard to the operative treatment of 
fractures open to the air. These fractures are open in two ways, 
first, by the violence of the trauma received causing laceration and 
crushing of the soft parts at or near the site of fracture, these injuries 
carrying deep into the wound any septic material on the skin, clothing 
or the body inflicting the damage; and second, by torsion and indirect 
violence, forcing sharp fragments within a limb to be protruded out 
through the tissues covering it. The first class contains all the poten- 
tial infection one can imagine; the second class fares much better 
and gives a much higher percentage of non-infection, because the open- 
ing is generally small and has a valve-like action around the protruding 
fragment, which may stick out but a brief period and be reduced by 
muscular action of the patient at the first attempt to straighten the 
limb. Nevertheless this woiind is exposed to the microorganisms on 
the skin and clothing which cover it, unless it happens that the 
individual falls or is thrown in a manner to drive the projecting point 
into the ground so that one cajmot say that any one of these open 
fractures is clean, and the best practice is to consider them infected 
from the very start. 

Treatment should be undertaken in three directions: 

1. Treatment of the patient's general condition as caused by the 
injury. 

2. Treatment of the infected wound. 

3. Treatment of fracture. 

First aid depends on the place of injury and the facilities at hand. 
If the patient is seen very shortly after the accident, and materials 
are at hand, the open wound should be drenched with half-strength 
tincture of iodine, after bleeding from large vessels is stopped by the 
application of hemostats or other means. The use of constrictors 
has been the cause of much damage in these cases. Untoward results, 
such as gangrene, or lowered resistance in a limb, that permits infec- 
tion to get headway with possible loss of the member, or permanent 
paralyses from application over the path of nerve trunks may follow. 
Unskilled persons apply constrictors too tightly. If a limb is mangled 
and crushed beyond hope, the constrictor may save from fatal hemor- 
rhage, but it should not be applied tighter than with force enough to 
stop sharp hemorrhage. Oozing is not harmful, but really beneficial 
from the standpoint of sepsis, and force should not be used that will 



124 TREATMENT OF OPEN AND CLOSED FRACTURES 

damage skin flaps for amputation stumps. Constrictors furnished 
in factory, mine, and railroad first-aid outfits are dangerous, and 
generally they are too narrow and are applied too tightly with many 
turiis instead of one or two loops of sufficient pressure to stop free 
liemorrhage. When an open fracture is seen with one on the limb, 
it is the first duty of the surgeon to inquire as to its necessity. 

With the bleeding reduced to a mere oozing, a sterile dressing is 
applied over the injured area. If sterile supplies are not at hand, 
frequently clean bed linen, handkerchiefs, or other material can be 
had. The limb is made as comfortable as possible by being bandaged 
to the body, a splint, or its fellow hmb^ and the patient hurried at 
once to quarters which will furnish opportunity for further care. The 
best place is the nearest hospital. No attempts at reduction, removal 
of foreign material, picking at the wound, sticking instruments or 
fingers into the wound, should be made in the first aid. This rule 
is without exception and if violated leads to much trouble. Should 
iodine not be at hand, the large, sterile dressing alone is sufficient. 
Stimulants, sedatives, or supportive treatment may be given if neces- 
sary, but no alcohol, and best merely warmth of extra coats or 
blankets and the most gentle handling in a recumbent position. Mor- 
phine hypodermically is good routine for avoidance of further shock 
and relief of pain. 

Consideration is due first to the patient as an individual. His 
physical condition in general, age, reaction to the trauma and the 
extent of the injury and its complications must be understood. Treat- 
ment that can be given a robust working adult without danger of 
untoward result cannot be given to a child or senile adult or a person 
suffering from a constitutional disease. If severe shock is present, 
autotransfusion by bandaging the extremities from the distal end 
toward the trunk can be accomplished before removal to the place 
of permanent treatment. This throws a large share of the blood 
circulating in the extremities into the trunk and head, helps maintain 
blood-pressure, and wards off exhaustion of the vital centers in the 
medulla. 

The matter of the value of trying to save a limb will be of immediate 
importance in many open fractures of long bones, and the general 
questions to be asked: Is tetanus or gas bacillus infection possibly 
present? Will the patient survive conservative treatment, involving 
months of confinement, infection, and the evils incident thereto? 
If the limb is saved, will it be useful functionally and cosmetically, 
or will it finally have to be discarded as in the way? 

Primary amputations are dangerous if shock is present, and opera- 
tion should be postponed twenty-four hours or more in cases of low 
blood-pressure, skin pallor, sweating and rapid, weak pulse, to obtain 
reaction. Amputation either immediate or at the time of recovery 
from shock is indicated: 

(a) When the soft parts peripheral to the fracture are lacerated 
and crushed beyond hope of repair or regaining circulation. 



TREATMENT OF OPEN AND CLOSED FRACTURES 125 

(b) When there is cu"ciilar destruction of all tissues at the site of 
fracture. 

(c) When the skin has been stripped from tln-ee-quarters of the 
peripheral part with subadjacent muscular damage. 

(d) When the important bloodvessels are known to be torn across 
and distal circulation is lost. Attempts at anastomosis or transplan- 
tation of bloodvessels always fail in the face of trauma of this 
character. Nerve injury is not so important. 

(e) When the bone is thoroughly comminuted with accompanying 
tissue damage. 

Estes of South Bethlehem, Pa., in an analysis of a series of cases, 
shows that S.S per cent, of open fractures treated conservatively died, 
while the average mortality after single major amputation is but 
4.54 per cent. The average disability from open fractures of the 
femur or from both bones of the leg is thirteen months, while amputa- 
tion gives a disability of not quite five months. He found^ on analyz- 
ing 724 major amputations that more attention should be paid to the 
amount of skin injury than to the condition of the muscular and 
bone laceration, and that open fractures which sever a large nerve 
trunk do not require primary amputation nor do those wdth injury 
to one system of bloodvessels when there are two in the limb. Sur- 
geons, after long experience with open fractures, are inclined to 
amputate to shorten disability and to allow return to occupation of 
some sort with an artificial limb. Months have been spent in conser- 
vative attempts to save legs which gave some function, to have the 
patient after a year or two seek amputation to obtain greater freedom 
furnished by an artificial limb. On the whole, attempts at conserva- 
tion are primary; partial or complete amputation can be done later 
with little added risk. 

Arrived at suitable quarters for permanent care, if conscious and 
suffering much pain, the patient should be given an anodyne. Cloth- 
ing about the part involved or the whole body, if wet and dirty, 
should be removed and dry blankets apphed. Shock is cared for by 
intravenous or subcutaneous injection of salt solution, from a pint 
to three pints, depending on the age and size of the individual. In 
this solution, in cases of severe depression, can be injected ten to 
fifteen minims of adrenalin chloride solution, 1 to 1000, mixed 
directly into the salt solution or injected slowly into the rubber 
tubing by means of an ordinary hypodermic syringe. The whole 
limb is now painted with iodine. Then parts of clothing, dirt, severed 
muscles, and crushed skin, are carefully and quickly picked out of the 
wound, under anesthesia if it can be safely given. If the fractured 
ends protrude, they are subjected to the same treatment as tlie rest 
of the wound. 

In some institutions where large numbers of compound fractures 
are cared for, this technic is carried up to this point, and when 

* Ann. of Surg., Iviii, 39. 



120 TREATMENT OF OPEN AND CLOSED FRACTURES 

the iodine solution has dried, the parts, bone and all, are scrubbed 
with green soap and sterile water to remove the macroscopic dirt, 
cinders, grease or foreign material which is ground into the wound. 
At Gary, Ind., and at South Chicago Steel Mills, in hundreds of 
these cases treated, this technic has been adopted as giving the best 
results from the standpoint of time of disability, infections, primary 
healing, and lessened permanent damage. The author does not use 
the green-soap scrubbing in all cases. If a large amount of foreign 
material is in the wound it should be so treated. Bloodvessels, ten- 
dons, nerves, are cared for with a minimum amount of surgical atten- 
tion; if tendons demand suture it should be done with catgut or 
kangaroo tendon. Bone ends are then reduced and placed in the best 
position obtainable, little or no suturing done in the muscle or fascial 
layers, and the wound left wide open, packed loosely with iodoform 
or plain gauze and a sufficient number of gutta-percha strips to ensure 
thorough drainage. A copious, dry, sterile dressing is applied, and 
some splint or fracture retention apparatus is loosely fixed outside 
to act as an immobilizer and protector. Much oozing of blood and 
serum will follow, demanding early and frequent change of dressings, 
so that the splint, if used at all, should be one that can be easily 
removed. At such dressings it is best to wear sterile rubber gloves 
and treat the case as though each handling were an operation itself, 
flooding the field with iodine to keep down bacterial activity. Anti- 
tetanic serum is given as routine. 

No foreign material such as plates, screws, or nails is put in these 
wounds, as they are drained from the start, and it is merely a question 
of time before some bacteria, if only saprophytes, will work into the 
tissues. If the bone has been handled, the soft parts disturbed enough 
to permit the drilling of holes for wires or the screwing on of a plate, 
and then infection creeps in, osteomyelitis of greater extent can be 
expected than if these procedures were not attempted at this time. 
The foreign material acts also as an irritant and tends to prolong the 
case. If a fair reduction has been accomplished, the wound handled 
as indicated, and the drainage removed as soon as possible, it is 
surprising what a large percentage will give clean healing or show but 
slight seropurulent discharge from the superficial tissues. The oozing 
and drainage are really helpful in two ways: they carry out material 
and mechanically cleanse the region and fresh blood constantly 
running over and out of the tissues furnishes antibodies in the serum 
to overcome infection. It is not denied that a plate or wire or even an 
intramedullary bone transplant may be inserted and a happy result 
obtained in some cases, but in the light of the evidence of several 
years' treatment in an institution where all degrees of cases are 
entered, the outline as given seems to have the greatest value. 

Men who use internal splints in fresh open fractures do not assert 
that they always get clean results, but they do assert that the fracture 
is properly reduced at once and even if infection follows and the plate 
is removed and the osteomyelitis is troublesome and demands further 



TREATMENT OF OPEN AXD CLOSED FRACTURES 127 

loperation. the final results are better. Immediate results are the relief 
iof pain, and firm fixation which lessens shock and promotes early 
^union. Fixation with Lambotte's rigid external plates is to be con- 

jidered if foreign material is used. 
One collection of 230 cases of open fracture has been reported by 

Pringle.^ ]\Iales in these cases predominated over females at the 
(rate of 9 to 1. The following resume covers the injuries: 

Immediate 
Cases. amputation. 

Upper arm 39 20=51 per cent. 

Forearm 30 9=29 

Femur 21 4=19 

Lee 139 33=23 

|0f the 230 cases, 10 died, 66, or 28.7 per cent., were amputated, and in 
159 attempts were made to save the limb by the opening of the original 
wound in the skin and subcutaneous tissues, which were cut away 
where bruised or where dirt was ground into them. All pockets were 
[spread open and made accessible to free drainage, gross dirt was 
j picked out, the bone ends, if found to be dirty, were chiseled off, 
and all small bone fragments which had been detached from the 
I periosteum, were removed. In some instances the bone ends were 
I fixed by wire screws or plates and attempt was made to close all 
wounds without tension, lateral incisions being made to relax the 
[tissues. Pringle believes that some fixation agent should be used in 
■the bone even if the wound is left open. He keeps wet dressings on 
[to avoid necrosis of the soft parts. One hundred and twelve cases 
were treated by internal fixation splints, and of these 9 died, from 
[such causes as pneumonia, heart conditions, nephritis, brain injuries, 
and secondary amputation, which was performed in 7 cases. Forty- 
seven cases were treated by the cleaning process alone. Of these 
14 died and in 7 there were secondary amputations. There were 
1 6 instances of sepsis and 3 of necrosis of the skin. Pringle believes 
that stripping of the skin away from the limb by the accident is 
1 very important as to the prognosis. There were no deaths from tetanus 
[in his cases, although the antitetanic serum was not used as a routine. 
Another advocate of immediate fixation of open fractures,'^ prefers 
!the gimlet and rod fixation, held in alignment by plaster of Paris 
or Freeman's external clamps, which are much like Lambotte's. 
He also believes that the intramedullary splint is contra-indicated 
and that complete drainage of the wound is necessary; so he packs 
it wide open with gauze after the application of the gimlets. Taylor^ 
u.ses the same method and ParkhilH and Freeman-^ do not differ greatly. 
Levison,*^ who advocates immediate operation of selected closed 
fractures, takes the .stand that open cases would be better handled 

' Brit. Jour, of Surg., ii, No. .5, p. 102. 

* Lillienthal, Ann. of Surg., Ivi, 185; and Iv, 883. 
' New York Med. Jour., May 13, 1911. 

* Ann. of Surg., xxvii. '" Ibid., 1904. 

* California State Jour. Med., February, 1914. 



12S TREATMENT OF OPEN AND CLOSED FRACTURES 

without internal splint and must be allowed to heal completely. 
Bartlett/ in an article on operative treatment, states that although 
no operative procedure is wholly without risk, we should show definitely 
why we assume a moderate risk before submitting any bone case to 
operation. Yet under his indications for plates he states that "it is of 
course desirable in all fresh widely open fractures if shock be past." 
Fredet, of Paris, always allows open fractures to heal and cicatrize 
before attempting repair of deformity. Wire is of no value, as it does 
not hold firmly enough. In open fractures the capillary vessels in the 
traumatized bone and lacerated tissues are thrombosed or destroyed 
and for that reason alone, triansplanted bloodvessels or bloodvessel 
suture will not be successful. The same result is manifested in intra- 
medullary bone splinting with autogenous grafts in these fields. 
Deprived of the normal serum supply and exposed to infection, the 
grafts will fail to live, and, though they may act as mechanical supports, 
their placement within the medullary cavity is so deep and covered 
that on their death complications are bound to ensue. If rigid fixation 
is to be used, a silver plate with silver pegs instead of screws, which 
can be removed in a short time, seems to offer the rational treatment. 
Treatment is a matter for each surgeon to decide for himself, but the 
careful handling described, allowing the soft parts to heal, even if the 
bone position is bad, seems good surgery. If infection is present, it is 
easier to eradicate and becomes less extensive as a rule, if no bone 
plate or other foreign body is present. Its course is shorter, as ample 
drainage has been present from the first. As indicated, no operation 
in which a plate or internal splint is used should be drained, and if such 
splint is used in fresh open fractures, the tendency is to sew them up 
too closely, with the result that the gathering serum and exudate 
are dammed back, and if infected, spread much farther. When healing 
has resulted in simple treatment and the skin is in fit condition, the 
area can be entered under the rules to follow for operative treatment 
of closed fractures and an aseptic prompt healing be hoped for, after 
the deformity has been corrected at leisure and the proper internal 
splint, if one is needed, has been used. 

THE RELATIVE VALUE OF NON-OPERATIVE AND OPERATIVE 
TREATMENT OF CLOSED FRACTURES. 

The factors entering into this discussion are, briefly, age and 
occupation of patient, cosmetic and functional results of treatment; 
dangers of an anesthesia; time elapsing since accident and condition 
of skin and limb in general; the operator's surroundings and his skill. 

1. Age. — Age must be considered. Children withstand operative 
interference and anesthesia less well than adults. Internal bone splints, 
excepting autogenous bone grafts, cause more irritation in children, 
either on account of the immature character of the bone or a lower 

1 Cleveland Med. Jour., xxii, No. 13. 



NON-OPERATIVE AND OPERATIVE TREATMENT 129 

infection resistance. Deformities and functional losses, which appear 
serious in adults, are not so important in the young, who have years 
to grow and many chances for natural overcoming of defects. On the 
other hand, elderly people, whb never expect to ^o laboring work, 
or those to whom age is a factor from the standpoint of arterial and 
cardiac changes, or anesthetic danger or rest in bed, should receive 
most careful consideration before being subjected to operation. 

2. Occupation. — Occupation is of importance in the making of a 
decision. If the patient's livelihood depends on the good use of an arm 
or leg,' as in all laboring classes, an attempt to give the best function 
in the shortest time should be made. 

3. Cosmetic and Functional Results. — Cosmetic and functional 
results, such as malunions, shortened legs, useless elbows or arms, 
angular deformities, are sources of embarrassment, and also through 
causing a restriction of activity in a person otherwise healthy, are 
worth considering when manipulative treatment without open 
operation has left the conditions. Open operation with anatomical 
reposition of fragments offers much to this class, not only in the way 
of improved appearance but also in the great increase of function 
which invariably follows when the axis of a long bone is put in proper 
alignment. In operating on forearm fractures where the displace- 
ment does not appear very bad, but where the function of the hand is 
far from good, one can demonstrate this effect almost as soon as the 
patient is out of the anesthesia, by getting freer and better movement 
in the fingers. 

4. Dangers of Anesthesia. — Dangers of anesthesia and prolonged 
splinting or rest in bed must be weighed in connection with age and 
such constitutional disturbances as bronchitis, nephritis, diabetes, 
tuberculosis, chronic alcoholism, syphilis, and tabes or general paresis. 
Many of these conditions give contra-indication, and they should be 
included in a careful general examination of a patient about to be 
subjected to bone operation of any magnitude. Particularly is this 
so when foreign material is implanted. 

o. Time after Accident. — ^Time after accident and condition of the 
skin and limb in general demand consideration. It appears best to 
delay from seven to twelve days after fracture before opening by 
operation. If pneumonia or delirium tremens or other untoward 
complications are to appear, they will usually show up within this 
period. Edema and swelling can be overcome by rest in a temporary 
dressing and the application of an ice-bag. The skin must receive 
careful attention. If abraded or scratched, or necrotic in small 
areas, it must be completely healed before the operation. Failure 
to observe this small point leads to many infections. Blebs and 
l)ullie frequently appear on a leg or arm many days after injury. These 
>hould be aseptically evacuated at their lowest point and the whole 
area dried and made smooth before operation. Levison^ makes a 

• Loc. cit. 



130 TREATMENT OF OPEN AND CLOSED FRACTURES 

plea for immediate operation such as Lane advocates, to avoid the 
early shortening of muscles and callus formation, and it is his experience 
that with a perfect technic no chance for infection follows. Lambotte, 
Fredet and DuJarier all wait for ten to fifteen days. 

6. The Operator's Surroundings. — The operator's surroundings and 
his skill are also important factors. Bone work should be done in 
properly appointed operative rooms where all instruments necessary 
are at hand and where the assistants and operating nurses understand 
the rigorousness of the technic and have been trained to obey it, 
because the operator must not have the worry of attending to them 
in addition to his own part of the work. Extension apparatus, suitable 
splints, plaster, large amounts of sterile supplies, and interested helpers 
are essential. 

The operator should have every confidence in his own technic, 
which should be acquired by watching men who practice frequently, 
aided by his own critical improvements after work on the cadaver 
and lower animals under conditions similar to those of real operation. 
This work requires the utmost patience, physical endurance, and atten- 
tion to details. Some operators are not fitted for it. The surgeon 
should never handle any suppurating wounds at times when doing 
this class of work unless he wears rubber gloves. 

After Lane's exposition of operative treatment, other arguments, 
pro and con, have been advanced by able surgeons, based on their 
own and their colleagues' experiences with the use of the steel plate 
and other devices introduced subsequently. Scudder^ considers it 
unfair to make comparison between the brilliant results of treatment 
by open operation and the rather poor results obtained by non- 
operative treatment, which is very frequently far from ideal in its 
application. The question arises whether we should not obtain 
better results from non-operative treatment if we put as much time 
and thought on it as we do on the other. The secret of the whole 
matter probably lies in the fact that surgeons and the profession 
as a whole have sadly neglected the treatment of fractures and until 
the advent of the roentgen ray both public and profession were 
satisfied with results. Since the enlightenment of this method of 
examination better treatment has been sought until, to quote Blood- 
good^ "more cases will come to operation when publicity has forced 
better methods of treatment upon the profession." The discus- 
sion of Scudder's statement, previously mentioned, brought out 
some firm opinions. Roberts, of Philadelphia, considered that too 
much operating had been done; he had two deaths in femur cases. 
G. G. Davis fittingly summed up the matter by saying that the man 
who gets too expert in an operation is dangerous. In another place 
Roberts^ likens the surgical treatment of fractures to surgical treat- 
ment elsewhere; inasmuch as operators desire to handle fractures as 
they do aseptic laparotomies, they get irked at readjusting splints, 

1 Tr. Am. Surg. Assn., 1913. ^ pr^g, Med., December, 1909. 

3 Arch. Int. de Chir., Gand, VI. p. 62, 



XOX-OPERATIVE AND OPERATIVE TREATMENT 131 

casts and bandages and have consequently taken to the use of internal 
splints which are left alone and require no subsequent manipulations 
to maintain good position. Hitzrot in a study of end-results of 
fractiu*es^ says : " Much of the present disability occurring in uncompli- 
cated fractures is due to neglect or lack of experience upon the part 
of the medical attendant. No method, however perfect, will succeed 
if improperly carried out in any of its details, and the too ready 
assumption of ability to treat any and all fractures on the part of the 
inexperienced lays the profession as a whole open to sharp criticism 
from Mr. Lane." 

Ashhurst,'- reporting 52 cases of forearm fractures treated without 
operation, believes that conservative treatment is as good or better, 
and that recovery takes place in a shorter time. Freeman^ states 
that the tibia is one of the most frequent sites of delayed union 
especially when operated on, and that Koenig asserts this is on account 
of the blood-clots which have been removed, their stimulation to union 
being lost. IMartin^ considers that in operative treatment the time 
is not materially shortened and that union is usually delayed and the 
results are not uniformly good, but that they are infinitely better than 
could be secured by non- operative procedure. 

The treatment of fracture is to restore function so that we must 
consider whether the interference with the soft parts in operation 
leads to additional disturbance. In the thigh we must not forget 
the importance of long-continued traction with a heavy weight, nor 
the position of abduction, nor elevation in children, and in women, 
especially on the forearm, of unsightly scars. Femur cases are those 
which come frequently to operation. Walker^ reported 21 cases 
treated by Lane plates, Lambotte's and Lohman's clamps, and says 
that "sufficient evidence has been shown to definitely recommend 
operation for fracture of the femur in such cases as reduction is 
inadequate — this requires the ends to remain in apposition without 
obvious angulation or axial rotation and shortening should not be 
over one-half inch." Moore^ believes that no operation should be 
done unless the patient's welfare demands it, considers the Lane plate 
the best fixation, and thinks that it is no detriment to the method 
to remove the plate when union is secured. It is also his opinion that 
the presence of a sinus is not a positive indication for removing the 
plate, as this sinus will often close with injections of bismuth paste or 
other applications. With this idea the author does not agree. 

There is much discussion as to the influence of internal splints on 
bone union, whether they delay it, favor non-union, or are detrimental 
in any wa\'. Personally I have had no cases of delayed union or non- 
union following the aj)plication of Lane ])lates. One case illustrated 

' Ann. Siir^., Iv, 33K. 

2 Am. Jour. Mod. Sfi., June, 1912, p. 843. 

•'' Ann. SiirK., September, 1911, p. .3H2. 

* Jour. Am. Mori. A.ssn., Oftol)or 21, 1011. 
5 Tr. Am. .Surp;. A.s.sn.. 1012, xxx. 

* Ann. Surg., Ivi, 1.5o. 



132 TREATMENT OF OPEN AND CLOSED FRACTURES 

ill the chapter on Fracture of the Femur resulted in bending of the 
plate because the man left my service, and his cast was removed too 
soon, and he was allowed to bear weight. Although the bone shows 
deformity, the plate was firmly applied, no screw became loosened, 
and a good bony union resulted in spite of the fact that the man was 
an alcoholic. Two delayed unions which I have had followed the 
use of bone transplants in the tibia. The first was for a non-union 
of two years' duration in which an inlay graft was used. A nail was 
used to fasten the transplant. Several months after an apparently 
good result the wound broke down and a sinus appeared. I removed 
the nail and finding poor bony union in the tibia also removed my 
inlay transplant whicji was alive and bled when scraped. Later a 
Wassermann test proved positive, and after antispecific treatment 
firm union resulted. The second case was a fresh spiral fracture of the 
tibia, which was treated by an intramedullary bone peg. Union took 
over twelve weeks, with no infection and no abnormal symptoms. 
Roberts,^ who likens open operation on bones to the former needless 
oophorectomies and kidney fixations, reports a case of a male, aged 
twenty-nine years, whose leg was plated for a fracture of both bones 
two weeks after it was injured. In six weeks there was no union; the 
wound was clean and remained so. After sixteen weeks the plate was 
removed and he was given calcium salts, but there was no callus nor 
infection in the fracture. Thirty-three weeks after the fracture he 
began to have a little union. Darrach^ says that it is his experience 
that firm union comes a little more slowly in operated fractures and 
that the smaller the foreign body the quicker the union. The results 
on the whole are much better, however, than could be obtained by 
other means. Plummer^ says plating delays union, and Blake^ says 
he saw cases of non-union in the femur supposedly dtie to wire, which 
when plated afterward, resulted in prompt union. I believe that 
union is largely a matter of careful approximation, especially in the 
femur; that sometimes in the leg bones one cannot get union until 
very late with any means. Men of experience in this work have had 
just such cases. If the fixation is exact, we naturally expect union, 
as the bone ends and periosteum are in good position to regenerate 
bone, provided the patient has no idiosyncrasy in his osteogenetic 
tissue. An interesting case in this connection is reported by 
Magruder^ from which he concludes that a closed fracture unites 
more quickly than one treated by the open method. His case was 
one of double comminuted fracture of both bones of the leg. One leg 
was opened and plated, the other nat, and the unoperated side united 
four weeks sooner. He favors the use of a tinned-steel annealed 
wire rather than a plate, as there is less foreign material to traumatize 

1 Ann. Surg., Ivii, 545. 

2 Jour. Am. Med. Assn., August 3, 1912. 

3 Jour. Iowa State Med., June, 1912. 

* Surg., Gynec. and Obst., April, 1912, p. 338. 
5 Am. Jour, of Surg., xxviii, No. 1, p. 1. 



NON-OPERATIVE AND OPERATIVE TREATMENT 133 

the soft parts. Lane advises operation on all fractures, as does Koenig, 
while von Eiselsberg operates on the patella only. 

Experimental study covering the type and results of different 
methods of internal hone splinting has been made by several observers. 
One of the most complete reports is by Hey-Groves, of Bristol/ who 
tried to decide whether rapidity and firmness of repair was better 
promoted by intramedullary pegs or by external plates and screws. 
He used mostly cats and operated on the fibula, because it is a separate 
bone and is supported by a strong tibia in these animals. His results 
showed that in fixation by plates and screws without additional 
external splint, the screw holes became enlarged, a process of absorption 
took place, and the plates became loose. Once they were loose, sepsis 
was very apt to be started. Long plates held by perforating pins, 
like cotter pins, which were bent back after passing through the whole 
shaft, gave good results with no sepsis and good use after two weeks. 
The union was complete and perfect with little external callus but 
much firm internal medullary callus. This was considered to be due 
to the pressure of the pins keeping the blood supply restricted in the 
periostemn so that he obtained an aseptic necrosis of the bone on the 
external surface up to the first pin on each side of the fracture. This 
does not coincide with observation on human bones by those men 
who assert that plating caused delayed union or non-union because the 
bone is deprived of its usual stimulus of friction and motion by the 
complete immobilization. Hey-Groves believes that the bone under 
these circumstances, instead of being alive with full vitality and repro- 
ductive activity, may be in an intermediate stage, circulation and 
tissue changes being at a low state but later becoming reactivated. 
Hence if the operative fixation is one w^hich lasts but a short time, as 
plates and screws which become loose, the fracture will become displaced 
long before union occurs. If the fixation is more permanent, delay 
in vital action of the tissues does not matter, and the limb can be 
userl for functional activities tvhile delayed repair goes on. External 
splinting in addition seems absolutely necessary. The mere size of the 
plate has nothing to do Avith the possibility of irritation because a 
large plate firmly fixed will remain in place indefinitely, while a small 
plate gets loose and causes trouble. So he concludes that if a plate 
is attached in such a manner that there is some movement or 
mechanical irritation there follows bone absorption, fluid collection, 
sinus formation and finally sepsis. If the plate has been in place 
long enough to give firm union all is well; if not, it hinders repair 
and may bring on sepsis. Experiments w^ere continued by using out- 
side metal collars of aluminum plate or steel, magnesium, or bronze 
aluminum wire, which were put between bone and periosteum. 
Mechanically the collars gave good fixation. When they were removed, 
beneath the collar the bone was bare but not necrotic, the collar had 
interfered with the external callus, there w^as a vigorous internal 

1 Brit. Surg. Jour., vol. i, No. 3. 



134 TREATMENT OF OPEN AND CLOSED FRACTURES 

callus, but the method had no value practically. If the collar were 
[)ut ou loosely to favor external callus it Avould allow movement. 
His experinieuts with intramedullary bone pegs all resulted in breaking 
of the peg. lie also used intramedullary pegs of decalcified bone with 
no success; similar pegs of gelatin and catgut were not strong enough, 
and pegs of horn and metallic magnesium were likewise of no value, 
as the magnesium absorbed too quickly. Intramedullary pegs of 
steel were tried with a small hole in the center, which was threaded 
with wire to allow it to be pulled down at equal length into each 
medullary cavity. In the femur, with this steel fixation, he obtained 
a tendency to excess callus, while in the tibia subnormal callus was the 
rule. Intramedullary splints of coiled wire were also tried, as they 
could be withdrawn, but they gave no good results. His best results 
came from transfixion of the ends of the bone with rigid extension of 
steel bars like Lambottes's or Hackenbrucks's external clamps, involv- 
ing no attack at the seat of injury. In all trials good union with 
small callus resulted. 

Fractures comminuted by crushing gave the following observations: 
(1) Fragments of periosteum left in situ gave good callus which was 
firm and solid, and functional result was excellent; (2) when fragments 
were removed, functional use was not so good as under (1), but the 
anatomical result was good. This I have verified in two cases done on 
man, one a femur, one a tibia; (3) exclusion of the periosteum gave 
good anatomical result, a good internal callus but no external callus, 
and the vigor of the changes of repair was impaired and a delay resulted. 

The conclusion naturally follows that union will result even if the 
periosteum is removed, but union is a slower process without the 
vascular supply from the periosteum. As every fragment of bone is a 
center of regeneration in a comminuted fracture, all should be retained 
except in those instances near joints where mobility rather than 
strength is desired, in which cases it may be best to remove loose 
fragments or replace them perfectly for fear that callus may cause 
ankylosis. Any method, then, of internal splinting which affords a 
weak or loose union is a failure, because bone has not the properties 
of wood or metal and will not allow a screw thread to burrow into its 
substance. Furthermore, it does not sustain the thread long if its 
surface is subject to strain on account of poor mechanical fixation, 
but if this fixation is strong and lasts beyond the time that bony union 
takes place to make the support rigid, the threads of the screws will 
not cut their way out. 

Corwin^ concluded from his experiments that copper and brass 
plates or screws cause pathological irritations and changes. On the 
other hand, steel, iron or silver plates and screws are non-irritating. 
Plates put on denuded bone, or on the periosteum produce the same 
favorable result, while plates which are arched to cause little pressure 
on the bone or periosteum give no better results than those which 

1 Jour. Am. Med. Assn., Ivii, 1351. 



NON-OPERATIVE AND OPERATIVE TREATMENT 135 

rest fiat. The force necessary to remove both clean and infected screws 
from bone was tested experimentally by Bartlett and Hewitt.^ They 
drove o4 screws, abont one-half of which were infected, into dog 
long bones. At inter\als of a few hours up to seventy-one days these 
were withdrawn in an attempt to ascertain the force required to dis- 
lodge them. This average force for No. 3, three-eighths inch clean 
screws in dog bones with a cortex of 2 mm. was 95|^ pounds. For 
infected screws the average was 41-g^ pounds. For human bones, with 
a much thicker cortex, No. 5 or No. 7 screws can be used and eight 
or ten are put in at one time. Consequently a much greater force 
would be required to dislodge them if they are inserted in an aseptic 
manner into a drill hole the size of the screw barrel, and driven down 
to the head. In their experiments no infected screws dropped out of the 
bone, hence there must be external force and leverage which pulls 
them out when they are infected in human beings. For that reason a 
long immobilization is necessary for successful bone healing w^hen 
foreign bodies are present. 

In delayed union and non-union following open operation for 
plating it seems that we must acknowledge that the fixation by the 
plate was mechanically inefficient; there was no equilibrium of tension. 
Screws became loosened either because of too early use or lack of 
external support, and the bone ends slipped and did not unite. The 
ideal method of fixation is probably the indirect method, since by it the 
site of operation is not invaded, no material of any kind goes into the 
fracture but through small operative wounds which are made quickly, 
often with local anesthesia, rigid fixation and alignment are accom- 
plished. As a result union is prompt and function very good, there is 
no sepsis nor fear of it, and the treatment is applicable to open and 
comminuted fractures. 

Until hundreds or thousands of cases done by an approved technic 
can be carefully compared with a similar number of cases handled 
by the best non-operative methods, a final decision as to relative 
merits is impossible. Certain facts seem already established. Asepsis 
seems to be the keynote of successful work, and the operator should 
be in position to control his assistants or have merely one of whom 
he is sure. Open operation has demonstrated that external splints 
have not given perfect results on account of the pull of contracting 
muscles, which is really secondary to the all-important fact that the 
fragments were imperfectly reduced to proper position. As time elapses 
less foreign material is used, more simple reposition is practised by 
open method, with absorbable material to hold if needed. Delayed 
unions also, are caused not so much by the foreign material as by the 
long immobilization considered necessary to avoid bending of plates, 
buckling of nails or breaking of delicate intramedullary splints. This 
immobilization per se is not so bad, except that it deprives the limb of 
that functional use which stimulates health in it. It is not the irritation 

' Jour. Am. Med. Assn., Ivii, No. 17, p. 1.347. 



136 TREATMENT OF OPEN AND CLOSED FRACTURES 

of movement that we have to thank in mobilized cases, as much as it 
is functional use and consequent normal healthful processes. Hence 
the value of early massage and light pressure and pulls in the loeight- 
hearing axis lines. No lateral stresses should be allowed. 

The reports of the committees of the English and American Surgical 
Societies touching on operative treatment of fractures are of much 
interest. The English recommendation is that the surgeon should be 
experienced and have suitable facilities for aseptic technic. No open 
treatment is undertaken where reduction can be made without incision. 
The best results are obtained by operating immediately «-fter the 
accident, and open work is not needed in children, because deformities 
disappear. They also warn against operation in old ununited frac- 
tures as these are frequent failures. The American Committee divide 
surgeons into three groups: 

1. Those who are inexperienced in the technic and requirements of 
open operation. 

2. Surgeons of experience with poor or average hospital facilities. 

3. Competent surgeons with excellent hospital and operating 
facilities and trained assistants. 

Class 1 is barred completely. Class 2 should operate only in case of 
urgent necessity, and Class 3 alone should make free and frequent use 
of the open method. 

Reviewing the operations for unopened fractures at the Cook 
County Hospital, Chicago, for seven years prior to 1914, one finds 
that there were 462 cases so treated. These were operated by different 
individuals and with various technic, very few with the asepsis indi- 
cated by Lane. It is interesting to note that there were 106 cases of 
patellar fracture operated out of a total number of 179 cases. All in 
the earlier years were wired, but gradually the kangaroo and catgut 
method of capsular and aponeurotic suture supplanted the wire, 
until at the end of the series very little wiring is recorded. Of these 
cases but 5 were infected. The same holds true of operated femur 
cases, of which there were 62, many of which became infected but 
resulted fairly except 2 cases which led to amputation and 1 to death 
on account of the infection. The fractures of both bones of the leg . 
were difficult to maintain clean, 64 cases having been operated in this 
period. The humerus gave but 24 cases. 

After the plate w^as introduced into use in America it is recorded as 
being used in 81 operations on closed fractures with variation in 
technic. Most of these were inserted on the tibia, the femur and the 
humerus, w^ith a few scattering elsewhere. On the tibia were frequently 
placed two plates. Of these 81 cases plated in the hospital, 44 were 
known to have been infected, demanding the removal of the foreign 
body, while 14 were followed by non-union. 

This gives a very high percentage of infection, but since the beginning 
of 1914 the number of infected cases has dropped, while the total of 
operative cases has increased. This is because of familiarity with 
the methods and better aseptic technic. Any figures gathered on the 



XOX-OPERATIVE AXD OPERATIVE TREATMENT 137 

work of men using decidedly different technic is quite worthless from 
the standpoint of the method's final value, but the statistics represent 
the results among a number of first class surgeons, and may be taken 
as an average result of a scattered group of the same number of 
operators. Individual results of men who pay strict attention to 
this work and its technic are much better. 

A very instructive resume of personal cases was made by Dr. George 
F. Thompson, of Chicago, at a meeting in INIilwaukee, in December, 
1913.^ Fifty-eight cases of patellar fracture have been treated by 
him without a single infection, and in the four years previous to his 
statement he treated fractures by open operation and plating one 
hundred and six times, with resulting immediate and remote infections 
in twenty-four instances. He believes in and practises a rigid aseptic 
technic but acknowledges that operators frequently forget and violate 
the principles without appreciating the fact, and he cites instances 
where the foremost men have made these slips. 

Open treatment for the correction of fracture displacements is so 
well established that a knowledge of its technic and the indications 
for its use should be as well kno^\^i as the standard methods of non- 
operative treatment. While open operation on fracture not exposed 
to the air is new in the sense of our asepsis, operations of this character 
have without doubt been done for centuries, but it is idle to use space 
reviewing that phase of the subject, as the author's purpose is to give 
exposition of methods now in use or contemplated. 

This branch of surgery is interesting, but demands painstaking 
care and hard labor, and the casual operator is apt to condemn open 
work if he does not do enough of it and has not acquired the technic 
by handling many cases. Part of his lesson is learned from each one. 
Statements expressed here are the result of the author's experience 
and observation of the work of many men and clinics, coupled with 
study of the best and most recent literature bearing on the subject. 
Lane's work has been the starting of this movement, and his well 
worked out ideas and beautiful technic will long remain a fundamental 
and be given due credit for opening this field. In past years operative 
work on closed fractures has been considered as in line with regular 
treatment in the case of certain bones. The patella has been looked 
upon as one of these, and the olecranon process of the ulna and others, 
ununited fractures, delayed unions, fibrous union and pseudarthroses 
have offered indication for operative interference. In most of this 
work little if any foreign material was used. Kangaroo tendon, 
ivory pegs and rarely nails of metal or silver-plated material were used 
but silver wire predominated. In certain classes, as those of the skull 
or spine, in operation for fracture or suspected fracture, foreign 
material was not used at all. These remarks apply rather to the 
long bones, the patella, and some of the flat bones as the scapula and 
mandible, and those cases which are primarily unopened to the air. 

• Railway Surg. .Jour., March, 1914. 



138 



TREATMENT OF OPEN AND CLOSED FRACTURES 



13 o 



11 


II 


lOO 


^CO 






?^ ?-> ?>i rt 

^ ^ ^ ^ 



g P C3 



,M^ 03 e CO 



-f^ I» (C (C t/j 

« 01 o) <u m 

O Qj a; <X; g^ 

a ^ ^ ^ is 



■73 T5 'O Tj "O 73 ^ 
OJ f-H (M I> CO rH ^<» , 



S ^-OTJ ^ S' 



ftfl 









3 G 

"a 



;n S3 
73 00 



2SS o 

n -e O 



03 O 






13 ■::3':;3 73':;3 



M-f? 



03 o3 9^ 

(U 0) a> Qj o 

QQQO Q 



'-S o o « += 



9S^ 



^^^M 






Wp^ 



S G o 



TSTJ^' 



o3 B o3 o3Bo3ojo3o3Bo3 

oo<ua)o'u<»o<ua)<»<iio<» 

OOQGOQQOQQQQOQ 



(2 0) 

a 
a o 



2-2 



03 o3 



CO 
(NOO 



>>>>>>>. 



cS oScSg (»o3o3o3 
13 TJTi ^ gT3T3T) 






"T^ "^ "^ "^ "^ 
i-l(McDCOCT) 



"7^ "XJ '~^ "^ "T^ 

CO 0> CO -^ Tt< "j; "J:* 'i^ 

1-1 i-H mmm 



(»»<ucSo3o3(Uo3(»aja)a)o3o3 

a s a^-^^ s^ s a s a^-^ 

03 o3 o3(M^i-H 0303 03 o3 c3 o3CMrH 



mmmm 



O •- to 
C 0) o 

lis 

<D a 

T3t^-43 
« 3 o 



02 02 ?; 

03 03 03 a 
13 73 "tS _,„ 



^ •2'S .S.S.S.S 



^(^^ ^O3o3o3aj cSc^^^^ ^^ ^o3 
q; q; q; a2 ^ <D O* c+h oo^q^c^o Q2(1:» Q^O 

Goo oooo^S ooooo oo oo 



Ti 
a H 



a 



2S 

O 03 



a 



aaaa 

o o o o 

o o o o 

(U <t) 02 « 

C G G C 

nil 



^a 



^S 



73 O O 



o o B 



1^ <« !^ 

ro'S's a ^ 

a ^ O O o3 

5 ^ o o a> 

is S "3 03 

j^t^ PI G • 

o3 eS O 



bD 



goo 

(S tH M 



t_, i-u >.u 02 zr 
42 M M !-, C 

> fl 3'C 
--3 03 o3 a+^ 

£ i 



3^ 



02 02 02 



tH a 

02 



•Kr"o3o3 Sji^o3eso JIJ^JT'^^ 

^OO SSWW^ ^SSS-cc 



as 

sa 



02 ^ 



o o_o ooooo o_o o_o 

'Oi'oj m'm'oi 0203 02 03 Oi 03 02 

020202020202020202020202 

aaaaaaaaaaaa 

aaaaaaaaaaaa 

lOOOOOOOOOOOO 
00000120000002 
Q20202Q20202Q20202Q202O 

QQQQQQQQQQQQ 



?a 



l-l _!-l O 



^^ 


02 02 


02 


iJ T! 


'0 ft^ 


T3T3 


T! 


■^ - 


_S-2 


T3-d 


TS 












aa 


a 


S-r.'H 


.".^ 


S G G 


Tl 


T) G^ 




G 4>^ 


il 


U 03 03 


c8 


eS--; Qj 


>fcfe 


^> 


^,^=3 


^^^ 






-^ 6, 


3 


"S i^S 


12 


OOO 


o 

1 


f\\. 



:3 o3 

aa 

02 O 



OOO 

aaa 



'a g 






'Z.K 



^M CO Tt<lC<© r-H^fOTt* 



^_02_O^ 

HT3T3-0 

I I I 
—i^co 



^^_o^-S 

Tj-cTS-d a 

■j2 '^3 »n M o 

^;s;§^o 
Mill 

Tf<iOCDI>00 



I I 

020 



§1 

I I 



^ 3 3 G o 
03 '^'^'^ G 
^ ►J G G G — ( -►i'— I 

_C3 g 03 02 03 03-3 03 
O W^uP^ S c3 S o3 

I I I I I I I I 

fO .-HiMCO^'OcOt^ 



^ ^ ^ 3 3 j3 3 



I I I I 

OOOOrH 



I I I 

CMCOt}* 



NON-OPERATIVE AND OPERATIVE TREATMENT 



139 



n 


month 
days, 
month 
weeks. 




month 
i mont 
weeks, 
weeks, 
month 


2 weeks 
weeks, 
weeks, 
month 


i 

is 


■5^ 
c c 

o o 

sa 


TfTH 


r-l(N-H(N 


INIMO 


(N(NI>CO;0 


0)l>Tt<(M 


Oi 


TJ<C1 



cu aj VI ui <n 1/2 ]^ 
(L £5 OJ 01 0) <u 0) £ 

is-o is ^ is pS is , 



«j »5-2 



is cs a 



a, o) ijj o o 
is is-d a e 

CCt>I>C^CO 



<D 4) R 
(U (U O 

is is a 



o 



Mo 

•I 2 






>< O o3 O 03 






£.a 

-i^ o o 

eft 

~ » t! C 



oooaog(K-(;g^ggooGOo3>< 



, o 



- 3... 

o.s'a'a 



o.^ o 



m m 

00 03 93-^ 05 CC CO 



63 K £ « c3 O 






43 M ^" ^ 



^ ^ 'G -3 73 T5 T3 "O "O TJ 
•'-'(N'-iOO(Nt}<CC><NCO 



(N 






^ ^ ^ -oj cj 



c3 03 c3 



uo. 



a G% c 

^ ^ oj ^ 



0) <u 



CfiCflCCCC 
QOOOOOOO 



G fl"S 


C G C fl S 


1:1 


G G G 


03 oS a; 


03 o3 cS o3 o3 








(D a; 0) 0) a> 




<0 (0 <o 






G 




OO^S 


UOOOO 


6o6 



*S.2 '5'x'x 



Qe ;::: 



5 s 



73 TS 
C3 03 

G G 
C3 C3 
c3 c3 



G 3 
C O o 






nil 



-2 a 



.4^ 



-c^ ^ T3 a r* 

a)2a>a)<uaJo3>> 



^p:;eL,fL^pLH^;£^r; 





??>> 


W) 


ao 








<u 




aS 


ft 


ft 




y 
y. 

d ivory 
amedul 


OJ 


<u 


1 >. 


G 


G 
>5 


s ^ 


liar 
liar 
an 
ntr 




S?^ 


-2 :=! 




S G oi 




G G oJ-'^ 






s -^ 


T3'C^ M 


T-i 


-0 a-- 




ins 


0) 


2i 0) fe 




a 


bOo) 03 


03 cS S <B a' 


03 


III 


Intr 
Intr 

Silv 
Bon 

Nai 


G 


►5 Km 



■^■s 22gF2 - _ 

^1 £ £ g— ? K ? ? t « i 5 5 c 5 „ 3.'H ? ^ ^ 

-^t r e.= ^25G^=-S5fe£ltisa =* = § 

.11 nirTj'TTTTTT'i tT?t TT\ 

■c-; r^xc-. p — ■M re -r ic -r t^ X c; o-"MM -r —I'M 



<u G 
to c 

?3 

to O 

OS'S 






G 2 o— c: o 

lilfpll 

I I I I I I I I 

^0 -t lO -i r^ X Ci o 



4* _. 



5 -i 



c3 03 O 
O CJ _^ 

l-i L< o3 

CC '» % 
I I I 



SftCO" 
•^SgG-g 

■&"ift§^ 

GJ3 3,2 a 

I I I I I 
-r 'O -o 1^ X 



•:l 



ci. a 



3 OX> 



ii, 



140 



TREATMENT OF OPEN AND CLOSED FRACTURES 



S5 



H.B 












.(OCCOl^tOUJ COM 

OOOOGOO OO 

aaasr„ss sa 



a° 



ats aa 



1=1 fl O 
P O g 



(P S 41 >i 
1^ ^,„ ^ ^ 



ICOt^fNiOt^CO "OiO CO ^OOOi (MTffCO lOiOOCC 






a ^ 



O o O O, 

o oi o o 
HffiOO 



o o o o 
o o o o 



-) 73 d o o o £ 3 rt ^ ^9 ,3 



> 6666 Q "l^ooot^p^HSPo;^ f5 a^o^ o^o 



^ ■ 



^OQ 



'^ ft 


.si 


C O 


t state 
days 
dfrac 
days 


S.2 


H^ 


l^°J^ 



■+-i >> « <D 
(O Js « OJ 



.lOCO'-H 



^ 




^ 


^^ 




O 

a 




03 g 03 c3 
T3 ^T3T3 


c« 


(NIC CD CO 


,—1 


C/J 










^Scoo3c3rt03o3raTO ra ra!ro3 o3o3fHirmS:ra 



■^'-liOOCC'-l'O-^CDt^ 



<N 



0i01> 






^03^^ 03 ^^rf^^c3o3^c5c3 ^ 

oooo o oOooooouoo O 



(3 fl C 


c a ti 


■Sec 


03 03 03 


03 (S e3 














»5oo 


OOO 


OOO 



a 

o 

1t\ 



aa 

03 C3 

1-1 1-5 



1-5 MP-iPhPh 



^C»PL,H 






T3 

a-d 



uj w w «^ w 

0) IK (B 03 S^ *• 

aaa^'a 

o3 03 o3 p,_a^ c« 

■g-g-g a^-s 



^ =« C3 



03 O 



> <D a; (u a> 3 
"oaaaS'^c 
o ac fl fi ft[ 



'^'S'Sfl^'^G '^ '^-^.'5 15 <u 03 03 o 0^ r -5 



-S i2 



to B 



CO 03 
ID .. 



^ 00 



'-r-, <KT3Sig 



CO 
•• C3 - 

p' 01-3 

S ftT5 

a a-- 

{^^^ 

I I 



_ ^_^ ^ dj a> 0) 

^^CD'-'OiO 

a^ J- . . . 

_ OoTSTSTJ 

"^ i <u.fc;.i3.t; 

tH >> O (_ t, t. 

a2 ^ a a a 
a" 03 a a a 

I I I I I 






c3 9 g aJ 

>>o3 C 5^ 



mooMgs '5 gg 



CO V^- 



ai 

a^. 



>> >>ij i a 






o.«-S "^:g g g g:g'7! 



5 "tS <u b ^ 

a g >>fiij 

S 73 .53 -^ -g ■;g 



5 C C ^. J^ ° 1 «^ " ^^ «^ 



a> ^ 



a s ^^ 
- ^ tH a s 

t? 73 03 S -tJ « 9* 






a«- 



I MM 

GO OO'-^'M -. . 



a-^ 



M M M M M 

■*>CC0l^00O5O'-l<NC0 



c 3 t, .^ t, 

"Sxi o «^ 2 a 



I Ml M M M M 
■>* iccor^ ooCT)0'-iiNecTi<io 

(N (NiN(N (N (N CC CO CO CO CC CO 



I 



NON-OPERATIVE AND OPERATIVE TREATMENT 



141 



















^ 








^ aj 






aj 






T 


J3 


-C^ 




^ 


^j= 


43 




-^ 35-C 






-^-C 


42^ 




!n-C 


weeks, 
month 
weeks, 
month 
month 
month 
r mont 
weeks, 
weeks, 
month 


^ 


^ 


C 


a c 


cf, 


a 


a c 


S 


^ 


c-^fi 


c 


c 


fee 


c a 


!!§§§ 


^,fl 


r, 








o it] 






o 


y 


o 8 o 






!i 




||ssa 


S O 


& 


^ 


S 


hid 


H^ 




bb 


b 


S&S 




b 


i-ti 


&a 


in 


t^ 


■<*< 


(NCO 


i-llXN 


(N(N 


<N 


■<* 


lOoectN 


(N 


Tt<00 


COM 


ot> cocoes 


COiO 


CO <N O IC (N (N (N :0 Ol ^ 


S 






-S 


















« 


^ 


^ 






§- 






o 
a 


.2 








1 








•43 


s- 


-a 







a 

■^ o o 
02 O 



<» <o S 

■3 '3-3 «t3 >,-3 
O O O c3 « S O 



-3-3 "3 

o o o 

o o o 

oo O 



5- <U-3 !- tn"^ 

ac.o Co o 

£ O O G O O 
^ O^^O 



-3 -3 ^-3-3 . 

O O o c o.^ 

O O o C3 O c3 

o ooh Ofo 



-3-3'3'3-3 -3 "" 

O O O O O O-t^ 

o o o o o o o 

OOOOO C^ 



OOOOoOOOo-^^ 
OOOOXOOOXO 

OOOOWOOOH2 



-3 -3-3 



« >1« >>>> >> 

® 03 « 03 S3 C3 

^TS ^ TSTS "3 

ecoeo (NO CO 

(N 



^ £-3-3 



03 e3 
-3-3 



-0-3-3 -3 -3 

t> "^ t> -^ '^ 



c3 c3 
-0-3 

osec 



'3t3'3'3-3'3-3-3-3'3 



r>. 








a> 






(D 




O 






















^ 






1 




^ 














■"' 








-% 






^ 




a 














*^ 








> 






a 




"" 














— 








o 






4) 




+j 














o 








a 




a 
o 


> 




a 
o 






















^ 




1 


_a 




-2 

a 














C 








1 




'B. 


c3 
















































|J 




w 




is 




1 


3, 




il 














cj o S 


c 


c a 


a a c 


m 


c 




a a a a 


a 


§11 


a a 


a 


a 


a a a 


a a 


aaaaaaaaaa 


O S C3 


c3 


c3 c3 


c3 cj C3 


03 


c3 o3 e3 o3 


03 


o3 03 


o3 


03 


c3 3 03 


c3 03 


C3c3c3c3c3o3o3c3o3o3 


rs 


o 


« O 


o « o 


O^^ 


a 


(V) u) <p 0) 


<S 


<» S 


« 




QJ CP O 


0) ai 


C^OQ^OCJCJOQ.'OO 










a 


















O 


OO 


OOO 


o 


oooo 


O 


OO 


OOOOO 


OO 


oooooooooo 












" 






o 


_« 








1 




"3 
















>, 


o 


"o 


'o 






a 




^ 
















V 




t., 


o 










o 
















s 


c3 


a 

-3 

e3 


a 






1 




-^a 
















3 


a 

03 


1 






'S 


-3 


h.2 MM MM 
















a 


S 








^ 


■^ 


3-2 <B <B <P QJ 
















03 


3 




5 






3 


3 


-3 >! a a a a 




















d 








j3 


"a 


C cp O o o o 
















a 


"^ 


o 


"S 






cC 


g_^^ ^X! 


>1 














>>T- >. 


>j 


c3 


>)- 


_ 




>> 


3 


2'3>>>. >.>» 
















Z. IS C 








0) 






h a (-< ^ u u 


_2 














^"B S 


_3 


a 


■ _§ 


> 




-1 


J2 


.a»=l^ ;^^ 


^ 














II 1 


3 

-3 


c3 


3 

-3 


« 




3 

-3 




^gill ^ II 


_^ £ 










1 
1 




a> o" 4^ 




_r 


<U 


a 




0) 




-3 


-3T3 


-3-3-3 


-c-o 


-3 


2 '"■3 a 


a 


S'C 


-r; a 


^"c 


-3-3-3 a 


^fliil^lii 


o 3 


o 


« « 


o « « 


® OJ 


0) 


o3 CO « rt 




h « 


O c3 


<n 0) 


D 


0) <P c3 


_ >> 








■»^:a *^ 


r^: -S 


-S 


£-0-^ i- 

lia^li 


u 


a -is 






-tJ 


■^.-a t. 


O o3 


llllllllll 




J 


3-2 


S3 ^ e3 


Is 


(S 




"S =s 


11 


03 


c3 -^ -M 


■s-^ 


z: a 






SzS 


o 




^ 


3-- 

72 Ch 


SE^^ 


h^ 



y o. o: 





O o " = 




ii 


s ztU 


IJIz^sls 


hlUl 










?iO 


m^^zz 


%5a "as "h 

ill ii 1 


1 


1 1 II 


1 


i. i, u 



- o 
" ? „, 

O) Oj 4) 



3 X 



? =3 h b s tc 

- M u <- ^ -3 

2 . - (u ju o tn 



^ u = ---a o 

t- r/j 1; 7) CO O fc. ;.. 

03 0; a s.- o a « 5 

-r a Q. a a-- q^ 



o 



03. a 
r„ a 



fci-3 

:a3 
r a 



a ■$ 
.a (K 






.2.2 "a 



r; 0: - 03 - rl rt C3 03-a 03 P-a-a C3 « c. 



I I I 



c o 

I I 
1 1.0 o 



aa .ao = oo£.5.-a 



.a o o o:=;.s;.« 

'I II I I I 

5 ^ CI 00 -1< lO -O 

1 CJ ri CJ ri CN C^l 



a-;= 

(NC>1 



Ml I 

SiO'-H'^i 



o.a o.a'3.-^ 

m aa cG OQ '/i o 

I I II f I 



142 TREATMENT OF OPEN AND CLOSED FRACTURES 

The accompanying table is a resume of closed fractures operated upon 
and discharged from the Cook County Hospital during the year 1914 
and part of 1915. The cases operated on during the seven years prior 
to 1914 with some classification as to the bone involved and the charac- 
ter of the internal splint used have been already given. These cases 
made a total number of 462. During the year 1914 and part of 1915 
there were discharged from the hospital 155 cases of this character, 
making a total list of operated closed fracture of 617 cases. For 
1914 and part of 1915 I have made a careful statistical review, which 
is interesting inasmuch as it shows increase in the number of cases, 
better results from the standpoint of asepsis and function obtained, 
and valuable detailed information as to the character of the operation. 
In this enumeration are included the skull and spine fractures which 
were operated upon for decompression purposes or the elevation of 
fragments, although no internal splints were used. Twenty-one 
different operators performed these, many of them using a rigid 
aseptic technic of a greater or less degree. One operation was 
performed by Sir William Lane. 

Reference to the table reveals the fact that out of 42 operations in 
which the Lane plate was used 8 were infected, giving a proportion 
of about 20 per cent., less than half the percentage of infections prior 
to that year. There was one death from pneumonia a week after 
operation and one two days after operation. Taking all the cases in 
which the plate was used during eight years, we find that 123 occurred, 
with 52 known infections or 42 per cent. plus. Two plates were re- 
moved which gave promise of later becoming infected. In 1914 the 
average length of hospital stay of all plated cases was seven and three- 
quarters weeks, while the average stay of the plated cases which 
w^ere infected was fourteen and one-half weeks, and of the 8 infected 
cases 6 still had small sinuses discharging pus when they left, and 3 
had been subjected to one or more operations for osteomyelitis following 
the infection. 

Thirty-four cases treated by intramedullary splints of autogenous 
bone yielded 5 infections, 2 of which cleared up in a short time without 
subsequent operation. One (a humerus) had an excessive amount 
of callus in which the radial nerve became involved, and although seen 
many months afterward had no discharge from the arm and refused 
to have the nerve freed and packed about with fat. There was one 
death on the day of operation from shock and two deaths at later 
periods as long as twenty-three days after operation. The average 
hospital stay of patients treated by intramedullary splints was fifteen 
and one-quarter weeks, possibly prolonged because we were anxious 
to obser\'e them until entirely well and to determine if possible the 
rate of absorption of the piece of bone within the canal. Two had 
large callus, which slowly absorbed later and after a few months 
was not noticea})lc. 

The operations in which nails and screws or both were used, 21 
in number, yielded but one slight infection and had an average hospital 
stay of eight and one-quarter weeks. The operations in which kan- 



IXDICATIONS FOR INTERNAL BONE SPLINTING 143 

garoo tendon or catgut was used yielded one infection also and had an 
average hospital stay of eight and two-thirds weeks. All the patients 
treated by laminectomy for fracture of the spine died except one, 
and of the 20 skull decompressions 12 ended fatally. Six fractures 
of long bones were treated solely by wiring, three by ivory nails or 
pegs and one each by silk suture and periosteal suture. The 6 cases of 
simple reposition without internal splint all terminated happily. 

SELECTION OF CASES— INDICATIONS FOR INTERNAL BONE 

SPLINTING. 

Not all fractures are considered objects for open reposition, plating 
or other internal splints. Under the heading of each bone discussed 
is given such types as experience has shown can be successfully sub- 
jected to operation. The foregoing points must be carefully weighed, 
especial attention given to the occupation, disability, permanent 
deformity, danger of sepsis and anesthesia. Fractures of the patella, 
olecranon, femur, greater tuberosity of the humerus and a few others 
seem to demand primary operation, under the restrictions mentioned. 
All fractures should be subjected to attempts at reduction and careful 
splinting, with the aid of anesthesia, if needed, before operation is 
undertaken. The results should be checked by skiagram. Marked 
shortening, irreducible deformities of rotation and overriding, 
deformities which will interfere seriously with function and wage 
earning, are indications for open replacement. Thoroughly impacted 
fractures near the joint offer strong indication for operation and 
should be considered minutely on consultation and with good skiagrams. 
They can frequently be benefited exceedingly. In brief, Walton's 
operative indications are to be remembered. They are: (a) implica- 
tion of joints; (b) neighboring dislocation; (c) failure to obtain a good 
position; (d) malunion; (e) involvement of vessels and nerves; (/) 
non-union; (g) separation of small fragments. 

Preparation for Operation. — 1. The Patient. — The usual preparation 
for anesthesia in accordance with surgical principles is made. As a 
rule these operations are long, especially if plaster has to be applied 
after the operative work and the patient kept asleep until this is set. 
Close attention to the skin condition as mentioned should be given 
by the operator himself. Small abrasions or ulcerated areas remote 
from the field should be covered with collodion seals. No patient 
recovering from an acute infectious disease, or possessing a known 
infection of any kind in the body, should undergo bone operation for 
fracture. Careful general examination should exclude any condition 
unfavorable to prompt healing of both bone and soft ])arts, and the 
patient should lui\-e explained to him the character of the operation, 
and the dangers of infection, should it occur, j^rovided he has sufficient 
intelligence to grasp the information. 

If extension by adhesive })laster has been used in attempts to reduce 
the deformitv, it must be removed and the whole limb shaved. Dry 



144 TREATMENT OF OPEN AND CLOSED FRACTURES 

shaving is the best, and the skin must not be nicked into by the 
blade. After the shaving the part can be washed in alcohol (95 per 
cent.) and then enveloped with a dry sterile dressing on the night 
before operation, or no dressing of any kind need be applied, that the 
skin may not become macerated but be in a natural condition. Clean 
bedding and night clothes should be supplied. 

When the patient is anesthetized, the part to be worked on is 
completely painted with tincture of iodine U. S. P. There should be 
no preliminary washing with water or bichloride of mercury solution. 
If the operation is upon an arm the surface from finger tips well up 
on to the chest is painted with shaving of the axillary hair if the 
humerus is to be opened; if upon a leg, the whole from and including 
the foot up on to the pelvis is painted, and the part remote from the 
field is covered with a sterile legging or towel, to be excluded. If 
extension is to be applied other than by manual force of the operator 
and his immediate assistants, this should be carefully arranged for 
before the limb is prepared, and the patient should be placed on the 
pelvic rest with suitable support beneath the back and head, and the 
extension from the ankle fastened. The patient once asleep and in 
good position, the skin preparation is performed and a clean sheet 
applied. If the skin is very heavy, a second coating of iodine can 
now be spread over the immediate operative field and allowed to dry 
slowly, following which nothing but instruments are to touch the skin, 
not even a gloved finger. 

2. Preparation of the Operating Room. — It should be warm and the 
windows closed, that a dust and microbe-bearing draft of air may not 
blow^ on the instrument table or the operative field. A proper supply 
of sand bags should be at hand, reserve sheets and gloves for the 
operators, and a sufficient number of non-operating assistants, who 
may be called upon to manipulate a limb in different directions, so 
that the operating help will not be led to endanger their own asepsis 
in doing this work and may be kept right in the operating field to 
prevent its derangement. When intramedullary splinting with bone 
from the tibia is to be performed, the area on the opposite leg from the 
side to be operated on is chosen, is prepared as for the major part of 
the work and is covered with sterile towels until time for opening. A 
good position for the large instrument table, bearing the heavy instru- 
ments, is directly behind the operator, the operative nurse w^orking 
alongside it. 

3. Preparation of Operative Nurse and Instruments.— The nurse 
scrubs in the usual manner and puts on gloves as soon as possible, 
taking care, as do all concerned in the operation, to put the gloves on 
without touching the finger portion with the bare hand. One sees 
operators with splendid operative technic putting on one sterile glove 
and then pushing on the fingers of this glove with the other bare hand, 
transferring to the glove in the rubbing process whatever infectious 
agents have not been removed from the hand in scrubbing. The 
instruments necessary depend on the operator. Large bone-holding 



INDICATIONS FOR INTERNAL BONE SPLINTING 145 

forceps are useful in all cases. Good drills are needed with a sufficient 
supply to provide for breakage or contamination during operation. 
Drills should be of such size that they will correspond to the screws, 
nails, or wires used. Chisels should be sharp, carpenter's chisels in 
sets of eight from one-quarter to two inches in width should be on 
hand, as well as heavy, long-handled periosteotomes, small and large 
saws, and an abundance of hemostats. 

Boiled instruments are laid out by the operative nurse, who uses 
large forceps with which to handle them, never touching any instrument 
with her hands. Needles are threaded with catgut by forceps, not by 
hands. The instruments used by the nurse are laid to one side, and 
that portion of them which comes in contact with the material to go 
into the wound must not touch hands. All instruments and sponges, 
plates, screws, etc., are handled by forceps and given directly to the 
operator or placed on the small instrument table near the field. The 
operator and assistants prepare with the same precaution regarding 
assumption of gloves. 

4. Operative Technic. — The Incision. — If bone plating is undertaken, 
the incision is made in the long axis of the limb on the side where 
approach to the fracture is easiest and involves the injury of no impor- 
tant structure. Long incisions are needed for plating. These should 
be made boldly in the first attempt, the knife cutting down through 
the skin alone, and then being laid aside. This is done because it is 
impossible to sterilize the skin through all its layers, and bacteria are 
present in the hair and sweat follicles which w^ill adhere to the blade. 
The skin opened, sheets of sterile gauze or light towels are placed along 
the incised edge of hemostats or special sharp-pointed clamps, to 
exclude the edge and all surrounding area from the open wound. With 
a fresh knife the incision is deepened, and fascia and muscles divided 
down to the bone. If small tendons or nerves appear in the field, they 
are avoided and retracted. The operator does not put his fingers into 
the wound; the assistants in sponging do not pick up sponges with 
their hands but use a forceps and after wiping out the field once, 
discard the sponge, picking up a fresh one. Retractors have long 
handles, and the end which goes into the wound never comes in contact 
with gloved hands. The closest attention is necessary to train one's 
self and assistants to maintenance of this technic. 

In approaching the point of fracture, one is guided by finding dark- 
ened extra vasated blood thrown out in the immediate neighborhood 
of the break. The bone ends once found, the area is palpated by a 
blunt nosed hemostat, and if necessary the muscles and fascia are 
reflected from the fragments and these are then caught in the grasp 
of bone-holding forceps. By means of local manipulation and extcMision 
or change of position by the assistant, reduction can be acc()mj)lislied. 
Even when the ends are serrated, by })atient efforts the fragments can 
be brought into perfect anatomical position. In oblique fractures with 
overrifling, the extension, which is furnished so completelx b\' the 
fracture table, must be held while the plate is applied, the fragment 
10 



146 TREATMENT OF OPEN AND CLOSED FRACTURES 

being steadied in the clasp of a large bone-holding forceps which 
permits the plate to slip between its jaws and be applied. Some 
operators do not appreciate the value of strong extension by mechanical 
means, and many devices have been brought out to force the bone ends 
into apposition. Bartlett^ suggested for lining up long bones a clamp 
which was composed of two parts, a male blade and a female blade 
with two prongs, the latter portion slipping down over the male blade 
and holding the bone in position by a thumb-screw. This is very 
useful after the bones are in extension. Colt^ believes that the turn- 
buckle brought out by Gerster is not needed if a Thomas splint is 
applied previous to operation and the elongation is kept up by an 
extension. Later Coerr^ introduced a double lever for reduction of 
overriding before the Lowman clamp is applied to hold the fragments 
during plating. The fracture table or suitable mechanical extension 
apparatus renders these devices superfluous. 

If a Lane plate or a bone, plate with bone screws is used, the technic 
of application is the same. The plate is held in the forceps and applied 
along the shaft of the bone. When its proper position is established, 
the first screw hole is driven well into the shaft with a drill, generally 
opening into the medulla. The screw is then applied by a screw- 
holding driver and is forced part way home before the grasping appa- 
ratus which holds the screw is loosened. It is then tightened and the 
remaining screws put in as quickly as possible. If bone or ivory 
screws are used in a plate of like character, they can be driven in as far 
as advisable and the remaining projecting portion cut off with cutting 
forceps. 

Experience and practice will teach the operator just how deep a 
screw hole must be for the size of screws used and the bone he is working 
on. If a screw is partly driven and sticks, it is as well to leave it alone 
if it holds securely as to attempt to withdraw it and redrill the hole. 
The work should be done quickly and methodically. Screws should 
be set in at right angles to the long axis of the bone and tightened 
snugly in a workman-like manner. Slovenly or umnechanical work 
has no place in this field, and the postoperative skiagram, which 
shows clearly the position of the plate and screws, is a good criterion 
of the operator's technic. In oblique fractures of the femur ^and some- 
times of the tibia, it may be necessary to insert two plates, one generally 
smaller than the other, acting merely as a stay across the fracture line 
at a distance around the shaft from the main support. 

Only large bloodvessels are ligated if bleeding. Oozing, which 
may be annoying at first, soon stops, and it is best to work without 
a constrictor for reasons already mentioned. If a vessel is ligated 
the knots must be tied with forceps; there must be no admission of the 
fingers into the wound nor handling of the catgut. In plating the femur 
with a ten- or twelve-inch incision, one rarely has to tie any deep 
points. Plates applied over the periosteum are less liable to cause 

1 Ann. of Surg., Iv, 998. - Ibid., Iviii, 490. 

3 Surg., Gynec. and Obst., xviii. No. 4, 521. 



INDICATIONS FOR INTERNAL BONE SPLINTING 147 

irritation and to interfere with union, nor do they later tend to be over- 
grown with bone. Closui'e of the incision is made by a continuous 
stitch of catgut, thi'ough the muscles and deep fascia. This must be 
applied by forceps, and the knots tied by forceps, and all tissues 
must be brought snugly together. The skin protection of gauze or 
towels is then removed and the skin closed, either by IMichel clips 
with exact approximation of the edges, or by interrupted silkworm 
gut with a finer horsehair suture in the incision line. The incision 
is then painted with iodine and a copious dressing to catch oozing 
blood is put on and bound with sterile roller bandages. Outside of this, 
the part being carefully held in its corrected position, the plaster or 
other splint is applied before the patient awakens and the position 
maintained until all is hardened and immobilization is satisfactory. 
No drainage is used. All structures are closed tightly, and yet there 
is oozing into the dressings. Drainage invites infection to travel 
down into the wound and is not necessary. 

If in certain areas other operative steps are demanded, they are 
indicated under the heading of each bone dealt with. 

Postoperative Care. — Casts, splints, and dressings must be in- 
spected frequently in the first twenty-four hours. When awakening, 
the patient must be restrained from violent motions which might 
displace the internal adjustment and when awake must be cautioned 
not to move the affected part. Should signs of local compression or 
interference with circulation appear, the cast should be cut away at 
once and loosened freely. If the oozing penetrates the cast, the 
dressings can be changed down to the skin through a window cut over 
the wound. Fresh dry dressing always stops the oozing. Casts 
saturated with blood begin to have a bad odor in a few days when the 
saprophytes cause fermentation. They must then be changed entirely 
and a new cast applied. Care in handling the limb must be exercised. 
If body casts or those involving the thigh or sacral region are applied 
they must be preserved against contamination with urine or fecal 
material. This is avoided by cutting them well away around the 
pubes and buttocks and using the bed-pan cautiously. By strapping 
the plaster edges with adhesive or painting them with shellac one may 
obtain further protection. 

Bed-sores, decubitus ulcers, may also occur. After body casts are 
applied the patient should lie on pillows placed squarely across beneath 
him, and the areas over the sacrum and buttocks should be inspected 
daily for beginning redness, which is sufficient indication to cut away 
the plaster and readjust the padding. 

After the application of internal bone splints it is very necessary 
that the external splinting should be of adequate strength, should 
immobilize, and should be left on for the proper period of confinement. 
One must consider that the bone fragments within have been delicately 
and positively adjustefl, sometimes under severe strain of mechanical 
extension, and the external splinting must take up this strain and 
hold the position obtained without chance of \ielding. In some ways 



148 



TREATMENT OF OPEN AND CLOSED FRACTURES 



the idea seems to prevail that internal splints, particularly Lane 
plates, are adequate of themselves to hold fractures without external 
help. This is a great error, accounting for many poor results, and should 
be corrected. The splint should be left on as long as if no internal 
splints are used at all, and the immobilization should be as complete 
as can be obtained (Fig. 34). 

The technic of removal of internal splints is simple. If pain, redness 
or tenderness about the site of insertion, or a sinus discharging pus 
develops at any time, the advisability of their removal becomes 
immediate. If the bone has healed in the position wished for and the 
signs of irritation develop late, the splint, if non-absorbable, should 
be cut down upon and removed. As a rule in plates, wires, and nails 
more infection will be found down in the bone than was anticipated. 
Around the edges of the plate there is frequently marked proliferation 
of bone quite completely embedding it, and yet granulation tissue 
will be found beneath when the proliferated bone is chiseled away. 




Fig. 34. — Removed bone plate after infection. THe attached bone and screws all lifted 

out in one piece. 

If non-union has occurred or the original plating was poorly done 
from a mechanical standpoint, or the patient was allowed to use the 
leg or arm before firm bony union had followed, screws will be found 
loose even in the absence of infection, absorption having taken place 
around the track of their insertion. Martin^ recognizes this fact and 
suggests that external support during the time needed for union should 
V)e firm to prevent twisting and angling strains at the fracture site. 
The same statement holds as to metal nails. The plate is removed and 
the granulation scraped away. The screw holes into the medulla are 
left alone unless there is evidence of virulent infection deep into the 
bone, in which event the medullary cavity should be chiseled open to 
remove necrotic bone and allow for drainage. The skin wound should 
be but partly closed after all is swabbed out with iodine, and a gutta- 
percha drain should be placed, extending out of the most dependent 
portion of the wound. This drains freely for some time, slowly fills 



1 Jour. Am. Med. Assn., Ivii, No. 17, p. 1353. 



IXDICATIONS FOR INTERNAL BONE SPLINTING 149 

ill from the bottom and in attenuated or weak infeetions is soon 
completely healed with no trouble. If sufheient drainage is not 
instituted or the wound is too thoroughly closed, pockets of i)iis form 
and burrow under pressure through the muscle and fascial planes. 

The technic of intramedullary splinting by autogenous bone grafts 
differs from that of Lane plates or silver wire or other internal 
appliances. The fractured ends being exposed by the same method as 
in plating, they are brought out through the incision by being grasped 
at each end with a bone forceps. If the fracture is one w^hich has 
healed in malposition, or one in which there has been callus throw^n 
out, it is often necessary to cut through the site of fracture with a 
chisel, making this cut at right angles to the axis of the bone. If the 
bone attacked is one of two, as in the forearm or leg, the companion 
bone, if not already fractured and loose, must be broken through 
likewise by chiseling, sometimes through a separate incision. In 
some instances cutting through the interosseous ligament will allow 
enough freedom of the fractured bone to permit insertion of the bone 

peg. 

The bone ends being turned out, if the fracture is fresh the medullary 
cavity is apparent, and the blood-clot in it is scraped out with a curette 
or reamed out with a reamer. If the callus has formed and has plugged 
the medullary opening, it must be gently cut away by a sharp chisel 
and the medulla opened in each fragment by drilling and curetting. 
The shaft of the tibia on the opposite side is next opened by an incision 
directly over its anterior edge. This incision may be straight or curved 
outward as desired. The fascia and sheath of the tibialis anticus muscle 
are opened and the tissues reflected back on both sides, the skin being 
held out of the w^ay by a broad, flat retractor. Measurement of the 
fracture will determine how large a piece of bone is needed. This is 
marked off on the tibial edge, each end indicated by a cross cut through 
the periosteum and bone wdth a metacarpal or rotary saw and the 
anterior edge of the bone sawed or chiseled off, with a broad-bladed 
carpenter's chisel. Practice with a chisel will lead to satisfactory 
removal of the splint if the electric saw cannot be obtained. An 
expensive mechanical sav>' is a nuisance if it is continually getting out 
of order, and it possibly opens a chance for infection in needing water 
to be dripped on the blade as it works, to avoid burning (Fig. 35). 

When the fragment of required size is loosened it is held in a bone 
holding forceps, not allowed to touch anything and while the assistant 
sews the muscle and fascia over the denuded tibial surface the operator 
returns to his fractured site and fits the splint into the medulla of one 
fragment, making sure first that it is not too long nor wide to fit into 
the opposite side, always holding the splint in forceps. If satisfactory, 
the splint is gently tapped into the medullary cavity and then by the 
manipulating of the limb to such an angle that the other end can })e 
slipped into the medullary cavity of the opposite fragment, the shaft 
is brought into alignment. This reduction completely- covers the 
intramedullary splint. 



150 



TREATMENT OF OPEN AND CLOSED FRACTURES 



Rotatory displacement is corrected and the bone will be found to 
fit perfectly. Closure is the same as after plating. This operation 
can frequently be done quicker and through a smaller incision than 
plating. 




i 



Fig. 35. — The bone field shows edge of tibia from which graft is taken, used in repair 
by intramedullary grafting. Clips show skin edge. In four weeks these shins often 
feel normal but skiagram does not show the bone filled in so early. 



INDICATIONS FOR INTERNAL BONE SPLINTING 151 

The site of the tibia from which the transplant is taken rarely gives 
any trouble. It should never become infected and usually after 
four to six weeks fills in clinically, so that the finger running down the 
shaft of the bone fails to find a distinct hiatus where the bone was 
removed. In some cases this filling in is greatly delayed — after four 
months I have found the depression still unfilled owing to complete 
removal of periosteum. It has been suggested by Trusiow^ that this 
defect be filled in with bone wax. Rarely there is pain if regeneration 
does not occur. The author has knowledge of three cases of frac- 
ture in the bone from which the transplant was removed, one in a 
child on whom an Albee operation was performed for tuberculous 
spine. Three weeks after operation the nurse in dressing the child, who 
had on a body cast, in turning it over hyperextended the leg which 
had been used for graft material, and a fracture through the site of 
removal followed. The second case followed an operation for an intra- 
medullary graft for spiral fracture of the tibia in an adult man. Two 
weeks after the operation, when he had been allowed up in a wheel 
chair, he slipped in getting from the bed into the chair, and in the 
effort to spare the fractured leg and save himself, threw all his weight 
onto the leg from which the graft had been taken, and a fracture of that 
tibia resulted. 

The third case occurred about ten months after the splint had 
been removed. The gutter had not filled in. 

The use of the fibula has been advocated by several men on account 
of its size and complete covering with periosteum. This is not the bone 
of selection, however, by a large majority, except in some instances 
of bone loss due to other causes than fracture. Gangolphe and Bertein^ 
suggest its use in comminuted fractures, but unless there is some 
necessity for employing the fibula the tibia is the bone of choice. Even 
in transplants for loss of bone Murphy suggests that this bone is not 
inherently large and consequently will not come up to expectations. 
Lewis^ and others prefer to use the anterolateral surface of the tibia 
from which to take the bone splint. If possible the bone peg should 
contain all three elements of osseous tissue, periosteum, compacta, 
and endosteum. 

The intramedullary autogenous bone peg comes very near fulfilling 
the requirements of an ideal fixation for fracture but it fails in some 
instances and we are forced to fall back on normal natural callus 
formation as the surest repair. In the last few months I have seen 
3 cases of refracture through an old site repaired by intramedullary 
peg. One in the neck, one in the shaft of the femur and one in the 
tibia. These cases were asepic and the roentgenogram showed plenty of 
calcified callus about the fracture site. The bone pegs had been broken 
off at the point where they crossed the fracture line Certain rules of 
bone-peg insertion remain to be worked out based on experimental 

1 Joiir. Am. Orthop. Assn., 1914, p. 299. 

' Lyon, Chir., xi, No. 6. 

3 Surg., Gynec. and Obst., xx, No. 6, p. 631. 



152 TREATMENT OF OPEN AND CLOSED FRACTURES 

and clinical findings. The most important of these, omitting asepsis, 
I heliexe is the degree of tightness with which the peg is tamped into 
the medullary cavity and the amount of preliminary destructive 
reaming out of the medullary cavity. These two points have great 
influence on the subsequent blood supply of the peg and the forma- 
tion of internal callus. For these reasons the inlay transplant, fitted 
snugly into the gutter cut out of the fragments, opposing like bone 
elements of the transplant in those of the bone fractured, becomes 
the anatomical and physiological method of treatment. 

In the use of nails or ivory pegs as internal splints, particularly 
near joints, the same rigorous asepsis is followed. Incision should be 
long enough to insure complete reposition of fragments and the 
nail driven through the most dependent portion of the loose frag- 
ment diagonally toward the shaft of the bone to which it is to be 
attached. Way may be made for it by drilling, but this is not so 
necessary with silver-plated wire nails as it is with ivory nails. Either 
kind may be driven in as far as wished and then cut off flush with the 
bone surface. 

Ivory pegs are useful and undoubtedly are ultimately absorbed. 
Where there is any fear of irritation from metal nails, or when there is 
proximity to a joint where a secondary operation for removal is not 
wished, ivory offers a good substitute for metal. The pegs are strong 
and wall stand pounding in deeply if a hole is prepared for them by a 
drill. The ivory plate and screws offer the advantage that they are 
ultimately absorbed and cause quite firm fixation but really have little 
advantage over the steel plates and cost much more. Magnuson^ 
and Brougham and Ecke^ have advocated them. The author prefers 
to sterilize them by boiling for twenty minutes and then keeping them 
for many weeks in a strong solution of alcoholic bichloride of mercury. 
This permeates them and does not seem to injure their strength. 

Unopened fractures that have healed in malposition and demand 
open operation are cared for by the same technic. When the site of 
fracture is exposed excess callus is chiselled off after reflection of the 
periosteum, and then the line of fracture is cut through. Placing the 
fragments in proper alignment, closing the periosteum down on the 
shaft and applying the Lane plate give excellent results. On account 
of muscular contraction of long standing some limbs cannot be extended 
or straightened out by mechanical means or tenotomy. In such rare 
cases the ends of the fragments will have to be cut off to allow for 
shortening. Intramedullary splinting is also applicable to these 
cases. Ununited fractures with and without pseudarthrosis, are 
primary indication for open operation. If a non-union does not 
yield to ambulatory treatment, to the pounding method of Thomas and 
Jones, or to other efforts, it is opened with the operative technic. 
Should no fascia, muscles or periosteum lie between the bone ends and 
the alignment be satisfactory, union may be stimulated by the driving 

1 Jour. Am. Med. Assn., Ixi, 1514. 

2 Surg., Gynec. and Obst., May, 1914. 



i 



IXDICATIOXS FOR IXTERXAL BOXE SPLTXTIXG 153 

of a drill between the loosely joined fragment ends. However, when 
the field is open, if one will elear off the bone ends with a sharp ehisel, 
it is surprising- how often interposition of these tissues is found whieh is 
not apparent from the view obtained through the ineision. As long 
as one is right in the area the best treatment is to freshen the ends 
and employ simple reposition of fragments with a slight shortening, 
or put in an intramedullary splint of such length and shape that the 
length of the leg is maintained. Plates should never be used when 
non-union or fibrous union is present. At the Hospital of the Good 
Shepherd they have almost abandoned the use of the Lane plates after 
twelve years' experience.^ They found that the failure to get reduction 
was on account of the interposition of extraneous tissues betw^een 
bone ends, and that external splinting did not offer good results on 
account of improper reduction and not because of muscular pull. 
Consequently they practice open operation with simple reduction 
and subsequently long immobility. ]\IacAusland- favors simple reposi- 
tion and cuts a small notch in the ends of the fragments if they tend to 
slip apart. Xails may be used merely as mechanical fixation to bring 
the freshened bone surfaces into firm apposition. Simple replacement 
by open operation should be given more attention than it has received. 
Removing interposing tissue and perfecting alignment in serrated or 
non-torsion fractures, gives good results. The operation is quickly 
done, and no foreign material is left, unless in some cases the fragments 
are tied together by heavy catgut or kangaroo tendon. 

Other Types of Operative Treatment. — It has been suggested by 
]Morris'^ that fractures be treated by pinning through a cannula with 
the aid of a fluoroscopic screen. This work demands a special table 
with slides which permit any part of the patient to be exposed to the 
Roentgen rays in front of a fluoroscopic screen. The operation is done 
under local or general anesthesia, the cannula is inserted obliquely 
through the skin and a drill hole is made to prepare for the dowel pin. 
This pin is inserted and tamped down after which the cannula is 
withdrawn. The skin is closed and an external splint is applied. 
I do not see what advantage this method has over nailing by open 
operation through a small skin incision. Morris admits that an 
error in insertion is possible, because the pin may be shoved along the 
shaft of the bone and may not fix the fragment as desired. One is 
more certain to see or feel these conditions through a small opening 
than through the fluoroscope. 

Bradford and Soutter^ advocate the fixation of fractured bone of 
infants b>- drilling through the bones subcutaneously })y means of a 
long drill with an eye at the point which is thrust out through the 
skin on the opposite side to its entrance. Strong catgut is threaded 
into the eye of the drill and pullerl through the bone by withdrawal 

' Van Duyn, Am. .Jour. Surp;., xxviii, No. 1, p. S. 
2 Surg., Gynef. and Cost., xix, No. 3. p. 404. 
' Jonr. Am. Med. Assn., Ivii, No. 17, p. 134.5. 
* Boston Med. and Surp. Jour., clxxii, No. 14. 



154 TREATMENT OF OPEN AND CLOSED FRACTURES 

of the instrument. As many catgut strands are inserted as needed, 
the bony fragments are coapted and the strands are tied over a steril- 
ized leather splint which stiffens in position. Other external splints 
are used in addition. 

Various clamps have been suggested for use in ununited fractures, 
some of which are inserted around the fragments, left a varying period, 
and then withdrawn. Morrison^ devised a clamp with five pointed 
teeth which was applied to the bone by open operation, and the handles 
were then withdrawn, leaving the clamp in situ. After B.ve to eight 
weeks, by means of a small incision and rocking of the clamps they 
were removed, the secondary wound healing in a few days. The five 
cases he reported gave no trouble from infection. Another clamp on 
this order has been proposed by Simmons.^ Ununited fractures are 
unpromising; the autogenous bone graft is the best treatment if the 
patient can withstand the shock of the operation. In the femur 
this is an important factor. Menton and Barton^ cite a case in a 
boy of an open fracture of the femur which healed after infection with 
two and one-half inches shortening, but operation was refused on 
account of the danger from shock. Traction in a limb may cause 
rapid fall in blood-pressure. 

In pseudarthrosis development between fractured ends, nothing 
short of the most complete exposure with dissection of the lining and 
covering of the false joint is of avail. Sharp dissection will remove 
every trace of a false joint and then the bone end should be sawed off, 
healthful fresh medulla exposed and a suitable intramedullary splint 
transplanted. These cases require an extra long immobilization of 
ten weeks or more, depending on the bone involved. 

Ununited Fracture.— The Inlay Bone Graft. — In his paper before 
the Congress of German Surgeons in April, 1914, Albee gave a resume 
of 250 cases in which he had used the bone graft.^ Most of these 
cases were in Pott's disease of the spine, but he mentions one case of 
spinal fracture without displacement or cord pressure which was 
cured by inlay bone graft, as in his operation for Pott's disease. He 
believes that the Lane plate is a hindrance to bony union in ununited 
fractures, but that fresh fractures demand temporary fixation only, 
because the fragments are osteogenetically active and the plate in 
suitable cases fulfils this requirement admirably. For ununited 
fractures the problem is different, as here one has to deal with bone 
sclerosis, rounded ends, and medullary cavities plugged with osseous 
material, as described in the chapter on Pathology. The bone graft, 
which contains both periosteum and endosteum and is a bone unit 
in itself, makes the ideal repair for this condition. Albee's method 
consists in sawing a long slot out of the shaft of the tibia by means 

1 Ann. of Surg., 1, 1114. 

2 Boston Med. and Surg. Jour., clxii, 174. 

3 Tr. Am. Surg. Assn., xxx. 

* Surg., Gynec. and Obst., 1914; Am. Jour, of Surg., xxviii. No. 1, p. 26: Ztschr. f. 
Orthop. Chir., abstracted in the Jour. Am, Med. Assn., September 9. 1911; Folder, Am. 
Orthop. Assn., May 15, 1911, etc. 



INDICATIONS FOR INTERNAL BONE SPLINTING 155 

of a two-bladed saw. This graft contains these elements and can be 
slid past the freshened line of fracture and held in place by dowel 
pins of bone inserted on the edges. (See schematic figure in the chapter 
on Fractures of the Bones of the Leg.) In 17 cases of ununited fracture 
he has obtained bone union every time by using the inlay graft. The 
principle of autogenous bone splints in ununited fracture is sound, 
because this graft is living tissue which has some resistance to bacterial 
infection, and it becomes fixed in the new bed made for it. By its 
presence it stimulates bone formation and probably also takes on some 
bone growth itself in the periosteal layers. Other surgeons have 
reported series of cases treated by both the intramedullary and the 
inlay methods. Henderson^ cites 32 cases of ununited fracture with 
satisfactory results. Five failures occurred, 2 each in the neck of the 
femiu- and in the humerus and 1 in the forearm. The other 27 obtained 
good functional results. He believes that the inlay method is better 
than the intramedullary, as the various bone elements of the graft 
are placed in contact with the corresponding elements of the fragments; 
that is, periosteum to periosteum, and cortex to cortex. Asepsis is 
as desirable in this operation as in plating, and the grafts must be 
autogenous and as a rule grow better in young than old individuals. 
The ingroTslh of new capillary structures from the fragments into the 
graft must be preserved by a long and complete immobilization, because 
very slight movements which involve the graft cause these vascular 
connections to be ruptured and their renewal is necessary for a success- 
ful result. If they are broken up many times it is but reasonable to 
expect that the capillary proliferation will become discouraged and 
finally cease, or the graft be deprived of serum so long that it will 
begin to undergo atrophy or necrosis. 

In fresh fractures the method of transposing the two strips of bone 
cut from the site of fracture has the advantage of obviating the need 
of opening the other shin for a graft. The grafts are cut wedge-shaped, 
wider on the periosteal than the endosteal surface, so that they will 
not slip into the medullary cavity and are changed about in accord- 
ance with that fact. They can be held in by sutures of kanagroo 
tendon applied through drill holes in the fragments or by small bone 
dowels as mentioned above. Albee says: "The grafts are removed 
from the fragments by starting the cuts with the twin motor saw 
adjusted to about seven-sixteenths inch (11.1 mm.) apart in a femur, 
then completing the cuts through the cortex to the marrow cavity 
'with a single motor saw. The longer strip of bone is then inserted 
into the gutter so that half of it is in one fragment and half in the 
other. 

"Dowels are now turned out with the motor doweling instrument, 
using for this purpose either the shorter strip of bone or bone removed 
from the side of the gutter distal from point of fracture. The graft is 
then forced into place and four holes drilled obliquely to its side 

' Jour.-Lancet, xxxiv, No. 73. 



150 TREATMENT OF OPEN AND CLOSED FRACTURES 

into the cortex of the ,i>'utter. The dowels are then driven into place 
allowing their ends to i)r()ject over and in contact with the periosteal 
surface of <>'raft. The inlay graft thus inserted afi'ords as secure 
immediate fixation as the Lane plate." 

These operations demand the best of improved bone instruments 
and either a fracture table or a suitable apparatus for making extension 
and the electric motor with its outfit of burrs, drills, and saws. Many 
electric saw^s have been put on the market; most of them are 
improved as our knowledge of the extent of their use and the power 
they require becomes apparent. An electrical outfit should contain 
the rotary saw, with provision for use of the double saw, several 
drills, two or three burrs, a trephine with a guard to prevent injury 
to the cortex, and a cranial saw for quickly cutting skull flaps. By the 
use of these special instruments and the Hawley fracture table we 
feel that there is a minimum of shock to the patient from extensive 
operative procedure and that the work of cutting out long and straight 
bone grafts, reaming out medullary cavities, opening the skull and 
cutting flaps on it can be done in the shortest time possible with the 
least inconvenience to operator and patient. The fracture table 
becomes invaluable when its use is appreciated. A leg can be held 
in strong extension at almost any angle with a continuous pull which 
relieves the assistants of hard work, makes the operative field less 
liable to mussing and infection, and permits the leg to be held in the 
desired position until the plaster or other splint is applied wdth less 
irksome work to the operator. 

External-internal splints have not been used much in America. 
The French are the most successful promotors of this method. The 
technic consists in the operator inserting screws or sharp-pointed rods 
into the fragments after sterilizing the skin and making a small in- 
cision in it or by complete exposure of open operation. By means of 
traction on these pins the fragments are brought in line, or they may be 
brought in line before the pins are inserted, and are then fixed by an 
external clamp in the desired position. The external clamp may have 
means within it for applying extension by means of a threaded bar. 
Infection is controlled by flooding the small wound or puncture 
frequently with iodine. External splinting with plaster is also necessary. 
In selected cases, as oblique fractures of the tibia, this method gives 
good results. Other means are the use of U-shaped staples with sharp 
points, the bone ends being brought into alignment and nailed there by 
the staple introduced through the sterilized skin. Little if any infection 
follows this maneuver if the iodine application is used. 

The Steinmann and Codivilla methods of continuous extension are 
dealt with under the fracture of the femur and leg bones. 

Lambotte's book must be read^ to get his whole idea. Many men 
have reported cases treated according to his method; Fredet reported 
in great detail 20 cases treated from October, 1911, to August, 1913, 

1 Chururgie Operatoir des Fractures, 1913. 



INDICATIONS FOR INTERNAL BONE SPLINTING 157 

and considers it particularly valuable in open fractures which have 
healed. Its troublesome aspects, according to him, are: 

1. It may crack the compacta. 

2. It holds poorly in the epiphyses or in friable pieces. 

3. Near joints there is not enough space to place two nails on the 
jiLxta articular fragment. 

4. A hole is left which invites infection. 

5. Maintenance of fixation on the arm is very difficult. 

He says: "Une fracture suturee n'est pas une fracture guerie," 
which might be translated to mean that the suture has no other 
purpose than to facilitate the natural course of healing, to assume its 
regularity, and to maintain the contact of the fragments. Dujarier 
favors wires which are put on encircling the bone fragments and 
removed after thirty or forty days. In the contemporary French 
Surgery department of the British Surgical Journal,^ Prof. Tuffier 
states that "we have completely given up the use of bone staples and 
employ plates and screws of many patterns." 

Recently Allen- recommends an external plate of an alloy metal 
poured and cast over the heads of nails whose shafts penetrate the two 
layers of compacta. When union is complete this cast is melted off 
and the nails drawn out. Good, strong nails or drills are used, inserted 
not in a straight line like screws in a plate, and a low melting alloy 
is moulded over their heads after the fracture is opened and reduced. 
This method seems far more elaborate than the Steinmann method 
or that of simple open replacement. 

Robert Jones has said^ ''Before we reach the new things we must 
ask ourselves if we have done the best by the old; and it is only by 
being critics of our own work that we can discover each for himself 
which procedure will in his own hands give the best results." 

' Vol. ii, No. 5, p. 157. 

- Indiana State Med. Assn. Jour., 1914. 

^ British Med. .Jour., December 7, 1912. 



CHAPTER VII. 
DISLOCATIONS. 

Definitions and Classification. — A dislocation or luxation is a 
complete displacement of an articular surface from the other surfaces 
or bones which form a joint. If the displacement is not complete, 
so that the joint surfaces remain in partial contact, the condition is 
called a subluxation. Diastasis is a term applied to separation of two 
bones closely attached to each other without a true joint. A tearing 
apart without lateral gliding is understood. Examples are separation 
of the radius and ulna at the wrist, or the lateral separation of the 
pubic bones at the symphysis. Distraction is an injury in which the 
joint surfaces have been pulled from each other without rupture of 
the ligaments which bind them or change of their axial relationship. 
Some separations of the vertebral bodies fulfill these conditions. 
Sprains and distortions are caused by forcible wrenching of joints. 
Ligaments and capsules rarely stretch; most of the injury is caused 
by tears of fibers or by the pulling out of minute areas of the bone 
surface at the insertions of the ligament. The relationship of the 
joint surfaces is not disturbed permanently, though there may have 
existed a momentary subluxation which sprang back into normal 
position. 

Dislocations are also classified as open or closed. When the joint 
cavity remains unruptured to the outside air it is called closed, and 
when the tissues are open to the air, open. Recurrent or habitual dis- 
location is a term which applies to those conditions which recur 
upon slight trauma or muscular action, generally aided by concomi- 
tant fracture and a defect or laxness in the ligaments and capsule. 
Dislocation of a joint which is healing after reduction of a recent dis- 
location does not constitute a recurrent dislocation. It is only when 
the trauma is trivial or a certain change of position easily induces 
the luxation that it is put in the habitual class. 

Spontaneous dislocations are induced by pathological changes in the 
bone or joint and are really pathological dislocations. They are caused 
by slight force and muscle action or simply by gravity and may 
occur with a patient lying in bed. Congenital dislocations, strictly 
speaking, are those which exist in intra-uterine life on account of 
anatomical defects. Practically this term is applied to many dislo- 
cations which occur during delivery or very early in life from infan- 
tile paralysis, because it is difficult to ascertain the exact time of origin 
of the luxation. 

Multiple dislocations are those in which two or more bones are 
dislocated simultaneously. They must not be confused with total 



ETIOLOGY A^D MECHANISM 159 

dislocations, a term which imphes that a bone is hixated at the joints 
of both extremities. (See Dislocations of the Clavicle.) Bilateral 
dislocations are double dislocations; that is, the corresponding joints 
on each side of the body are dislocated simultaneously. There is no 
settled nomenclature descriptive of dislocations. Involvement of 
the large joints, as the knee or hip, are spoken of as dislocations of 
those joints, and the distal bones are the ones which are meant as 
being dislocated. Further to clarify the type of dislocation, it is cus- 
tomary to add the direction the dislocated bones take. For example, 
at the knee one speaks of dislocation of the knee forward, backward, 
or laterally in or out, meaning that the distal bones, the tibia and 
fibula, are carried in the direction indicated. When one or both bones 
in the limb are mentioned as dislocated, it is customary to speak of 
dislocation of the radius forward at the elbow or at the wrist, or to 
use the anatomical names of the portion of the bone displaced, so that 
no doubt will exist in the reader's mind. (See Occurrence of Dislo- 
cations.) 

Stimson states that dislocations as compared to fractures occur in 
the proportion of about one to ten. During a period of collection of 
fracture statistics at the Cook County Hospital based on 11,302 
cases, 775 dislocations were cared for. There was a slightly higher 
proportion of dislocations in the winter period. Of 775 cases, 690 were 
in males, 8o in females; 87 dislocations were in children, 69 male 
children being injured to 18 female children. Of the total number of 
dislocations, 409, or 52.8 per cent., were of the humerus. In accordance 
with the statistics of the previously mentioned cases, the fourth 
decade of life contains most dislocations, the fifth, sixth, third, seventh, 
second, first, eighth and ninth following in order. 

Etiology and Mechanism. — Most dislocations are produced by 
external violence or muscular action and are consequently traumatic. 
The small proportion which are spontaneous are really pathological and 
are induced by changes existing in the bones or articular structures. 

The causes of dislocation are divided between predisposing and 
exciting. 

Certain predisposing conditions favor dislocation. The fact that 
there is motion in joints, that bone ends are held in contact by air 
pressure and surrounding structures, and that they are exposed 
to traumatic injuries which tend to overreach the physiological limits 
of motion, all tend toward dislocation. The action of powerful 
muscles across joints, effusions and hemorrhages into joints, which 
distend a cavity usually empty and weaken its soft structures, slow 
unnoticed pathological changes and fractures of associated bones, are 
also factors in production of dislocation. 

The exciting causes are external violence of either direct or indirect 
character and muscular action. 

1. External Direct Violence is a Rare Cause. — To cause dislocation 
in a healthy joint, direct violence must be so applied to the bone as 
to cause its holding ligaments first to give through being torn and thus 



IGO DISLOCATIONS 

to allow the bone to be pushed from the johit. Powerful direct blows 
on the front of the humerus head may tear the capsular ligaments 
and drive the bone directly back under the scapular spine. Falls 
may accomplish the same result. Neighboring bony structures which 
interfere with this exitus may be fractured, or they may be broken 
first and the continuance of the force may drive the dislocated bone 
into displacement. The fibrous ligaments are quite inelastic; the 
displaced bone tears them apart, and all that is needed for reduction 
of the displacement is the pushing of the bone back through the same 
opening. Unfortunately the muscles or tendons which pass over the 
joint interfere with this procedure, and their action has to be reckoned 
with. Dislocations caused by direct violence which ruptures all 
restraint are easily reduced and also easily slip out of place again. 

Dislocations caused by indirect external violence are very common 
and are more difficult to reduce because the bone is not disijlaced in 
direct line of the trauma. The principle of leverage ejiters into these 
dislocations, as the force acts at one end of the bone and the disloca- 
tion occurs at the other end. 

Joints are divided into sliding, hinge, and rotatory, of which the 
hinge joints, represented by the phalanges of feet and hands, elbows, 
ankles and knees, are the more numerous. Leverage action does not 
have much influence on sliding joints, which are displaced laterally 
from each other. In hinge and rotatory joints we find most often a 
lever action on a bony or ligamentous projection as a fulcrum. The 
three types of levers* must be remembered: (1) The fulcrum is 
between the power and the resistance; (2) the resistance is between 
the power and the fulcrum; (3) the power is between the resistance 
and the fulcrum. The mechanism of the first class, the fulcrum 
represented by a bony point or a strong ligament lying between the 
power applied at one extremity of the bone and the resistance of 
ligaments at the other end, covers most of the dislocations of long 
bones. The second and third class levers represent the dislocations 
caused by direct violence, because in these two classes the power and 
resistance move in the same general direction. Leverage mechanism 
of the first class is found in joints subjected to indirect violence in 
which the normal extent of motion is reached, or in which by reason 
of ligament restraint no further motion is possible because bony 
joints infringe on each other. When joints are flexed, there is no 
strain on them, because their movement is checked by the interposition 
of soft parts. When they are placed in extension, however, the check- 
ing restraint is either ligaments or ligaments plus a projecting point 
of bone or an articular cavity. If the indirect violence forces motion 
beyond normal limits after the ligaments are made tense, the ful- 
crum exists in the ligament or bone mentioned, and the resistance 
of the ligaments is overcome, the bone being displaced into dis- 
location. Violence, either direct or indirect, acting on a joint in a 
direction in which motion is not permitted, as lateral motion at the 
knee, may produce a dislocation, but the force applied must be much 



ETIOLOGY AXD MECHAMSM 161 

greater than that which causes ordinary dislocation, and fracture 
often accompanies. 

In specific types of joints the mechanism is as follows: For the 
phalangeal joints of the hands and feet as well as most of the meta- 
tarsal and metacarpophalangeal joints, the ligaments are situated in 
such a manner as to prevent extension much greater than a straight 
angle. If the distal end of the finger is bent backward suddenly, it 
acts as a lever of the first class, because its base presses against the 
proximal phalanx, which acts as a fulcrum, and when the ligaments 
on the palmar surface yield, the dislocation follows. Reduction is 
accomplished by flexing the overextended finger back into normal 
position. In some joints the tendons, muscles and fascia may inter- 
fere because of their mechanical presence, or because button holes 
have been punched in them which catch around the displaced bone 
ends. 

The principle motion in ball-and-socket joints is abduction and 
adduction. The shoulder- joint has the greatest movement of all, 
because it articulates with the movable scapula and not with the rigid 
pelvis, as the femur does. Davis^ says, *'The consequence of this 
(motion) is that the traumatic force is diverted by the movements of 
the parts in response to the blow, and what appear like direct luxations 
are really indirect." Luxations of direct violence without the inter- 
vention of leverage action vary according to the direction of the 
injury, as has been stated, but indirect dislocations, in practically 
all of which the lever force is working, conform more or less to a type 
and are of regular character, because the lever action can become 
effective only when the distal part assumes a certain definite relation- 
ship to the proximal part and a fulcrum is supplied. In the chapter 
on the hiunerus there has been something said about abduction 
injuries at the shoulder. The abduction mechanism of this joint 
has been worked out by experiments on the cadaver and by clinical 
observation and can be easily verified. When the arm hangs at the 
side, or is brought forward across the chest, or is drawn backward, 
it always comes into contact with the trunk, and since there is there- 
fore no fulcrum to act as an aid for dislocation, in these positions the 
arm cannot be dislocated. If the arm is abducted, a hyperabduction 
from trauma causes the tuberosity to impinge against the edge of the 
acromion, and a bony fulcrum is formed. The violence continues and 
ruptures the capsule on the opposite side of the joint and the head 
of the bone is pried out of the socket. The anterior inferior portion 
of the capsule is the site we would expect to be ruptured if leverage 
action is the cause, and this is found to be so. All other causes of 
shoulder dislocation are relatively rare. 

2. Muscular Action Causes some Dislocations. — Tetanic contraction 
of one or a group of muscles acting uii()])posed by the muscles which 
normally covniteract them ma\' produce dislocation in a normal joint. 

' Tr. Am. S.i>" V-t, I'M?. \\\, .".ss. 
11 



162 DISLOCATIONS 

The muscular contraction may furnish the force which acts on the 
bone Hke indirect violence. The common example is dislocation of 
the lower jaw caused by muscular action while yawning or laughing. 
The humerus or tibia may be dislocated by sudden momentum trans- 
mitted to it by muscular action in violent kicks or efforts at throwing 
which miscarry. Voluntary power of dislocation is seen in some 
individuals. The proximal joint of the thumb is the one most com- 
monly affected by volition. Such joint structures finally become quite 
lax. Some years ago a man of normal appearance made the rounds 
of the medical colleges who could voluntarily dislocate many of the 
large joints in his body. He had acquired the power by constant 
exertion and practice, using muscle contraction of certain groups over 
which he had an exact control. Some individuals can dislocate one 
or two joints voluntarily after having suffered a traumatic dislocation. 
The joint remains normal when the individual does not desire to throw 
it out of place. The tetanic muscular contractions of epileptic convul- 
sions, strychnin poisoning, or tetanus may cause dislocation, although 
many of the reported cases are undoubtedly caused by the indirect 
violence of falls received in the convulsion. 

The term snapping joint or trigger joint "has been applied to a 
condition of subluxation of joints which is voluntary and caused 
by muscular contraction. The reduction is spontaneous, and the 
act of subluxation can be repeated over and over. The muscular 
jerk which pulls the head of the bone from the socket may be uncon- 
sciously performed or may be influenced by efforts to seek damages 
or to avoid military service. When the joint reduces itself there may 
be an audible snap, and the joint may be seen to jerk back into normal 
position. Almost any joint can be affected. Those most commonly 
found are the hip, shoulder, and knee. I have seen two cases in the 
thumb. Bertein^ believes that the condition is a subluxation and that 
the peripheral snap of the bone is dependent on joint displacement, 
generally caused by a congenital or acquired laxness of the capsule. 
Worms^ records a case of snapping shoulder- joint in a lad. He could 
produce a loud noise in the joint by outward rotation of the horizon- 
tally abducted arm. Two cases of snapping knee have been recorded 
by Billet.^ These may arise from congenital arthritic changes or follow 
trauma and are very rare. Billet describes the mechanism as a per- 
manently recurrent subluxation of the semilunar cartilages permitted 
by the laxness of the capsule and ligaments. 

Snapping hip is recorded by Worms,'' Coudray,^ Miiller^ and Mou- 
chet.^ Mouchet^ believes the condition is entirely voluntary. 

1 Rev. di Chir., August, 1914, p. 711. 

2 Rev. Med. de I'Est, 1914, Nr. 1, S. 18. 

3 Gaz. des Hosp. 86 anri^e. No. 61, p. 997. 
* Loc. cit. 

6 Arch. gen. de chir., 1914, viii, Nos. 3 and 4. 

6 Berl. klin. Wchnschr., 1914, p. 1210. 

7 Gaz. des Hosp. 87 annee. No. 22, p. 349. 

8 Loc cit. 



PATHOLOGY OF DISLOCATIONS 163 

The characteristics of snapping joint are that motion in the joint 
affected is usually not limited. There is ease in producing the noise 
and subluxation by muscular contraction. The act can be repeated 
an indefinite number of times, reduction is easy and spontaneous, and 
the cause is some pathological laxness of the joint structures. As a 
rule the condition is painless. Various treatments have been suggested. 
Rest, electricity, baking, and operative treatment have been used. 
Excision of the joint cartilage or capsulorrhaphy have caused cures. 
iNIiiller cured a snapping hip in a fifteen-year-old girl by applying a 
corset with a band around her thigh and a steel spring like a truss 
which made pressure behind the greater trochanter. 

Habitual or reciurent dislocations are seen in the shoulder, jaw, and 
hip. They nearly always follow a traumatic luxation in which the 
joint has been distended and the capsule made lax. Paralysis of 
muscles which aid in the retention of the bones within the joint may 
contribute some help in the occurrence. They permit a laxness about 
the joint, and a slight trauma is all that is needed to throw the joint 
into displacement. The wearing away of protecting bone edges or 
their fracture, particularly of the glenoid rim, may also be of influence 
in recurrent dislocation. This class does not include the spontaneous 
dislocations, which generally remain permanent because the bones 
are pathologically affected, and while displacement occurs the con- 
dition is hardly a true dislocation. Unequal growth of two parallel 
bones may cause the dislocation of the faster growing one. This is 
seen in the forearm and leg. 

Pathology. — In ball-and-socket joints exposed, as we have seen, 
to leverage action of luxation, the articular capsule and ligaments 
are torn quite uniformly to permit the head to escape. This tear 
may be a longitudinal or transverse slit. It may involve but a small 
part of the capsule or a large part of its circumference, or it may tear 
off the edges of the bone to which it is attached. Muscles inserted 
near the end of the dislocated bone may be torn from their attachment. 
The spinati muscles frequently tear out the greater tuberosity of the 
humerus in dislocations of the shoulder. In extreme violence the 
bone head may be pushed through other more remote muscles or even 
through the skin to the outside air, making open dislocation. Recur- 
rent dislocations or traumatic dislocations, preceded by effusions 
within the joint or loss of tone in the periarticular structures, may 
permit the bone head to escape from the joint without tearing the 
capsule. The structures become so lax that the head will assume its 
new position, dragging its attaching ligament with it without tearing 
the capsule. 

When other forms of joints are dislocated, the capsular structures 
may be torn completely around the joint or simply on one side. As 
a rule, the capsule is torn on the side toward which the bone is dis- 
located, but both sides may be lacerated and only a few shreds persist 
which holfl the bones together. I have had a case of complete dis- 
location of a normal knee forward which gave no clinical evidence of 



164 DISLOCATIONS 

tearing the capsular structures. There was no hemorrhage or effusion 
in the joint, and after reduction there was httle or no swelHng in the 
knee. Another variation of the local pathology is for the capsular 
and other ligaments to remain intact, but the periosteum, which is 
continuous with the capsular ligament at its insertion, to be stripped 
off the bone and carried along with the dislocated end, leaving a 
space between it and the bared bone. This space quickly becomes 
filled with blood. Bony fragments of varying size may be lifted off 
with the periosteum. The articular cartilages are sometimes split 
or indented by pressure of the bone ends. Tags of capsular ligament 
or synovial membrane may come to lie between the joint surfaces. 
The edges of the bone or spines within the joint, as in the knee, are 
frequently broken. 

The displacement of dislocations is rarely great. Strong muscular 
attachments, ligaments and tendons about joints, the softer parts, 
and the restriction of untorn parts of the capsule, forbid a great dis- 
tance of separation. The position of the bone immediately after the 
dislocation is called the primary displacement. It often changes. 
The position finally assumed is termed the secondary displacement 
and is influenced by gravity, weight of a limb, swelling and edema, 
contraction of muscles, and the resistance of the untorn ligaments. 

Pathological Complications. — These comprise local injuries of the 
bones, vessels, nerves, viscera and soft parts in open dislocation. 

1. The bones are often injured in the manner previously described, 
whereby splinters are separated, periosteum is elevated, or an edge 
is cracked off. Though they are not serious complications, they really 
have a bearing on treatment and prognosis, and the surgeon should 
endeavor to diagnose their presence. A common example is the frac- 
ture of the tuberosity of the humerus. Breaking off of the edge of 
the glenoid or the acetabular rim is often overlooked and becomes a 
matter of considerable importance in after-treatment. Many cases 
of ankylosis or restricted joint motion are caused thus, the joint 
being used too early and too freely after reduction. Irritation is set 
up around the bone fragment and callus forms, often spreading out 
and involving the capsular ligament or causing an exostosis which 
hinders joint freedom. 

The dislocated head may be indented, its cartilage may be split 
or denuded, or it may be fissured down into the shaft. These compli- 
cations are not very troublesome, if they are recognized and the 
joint is given sufficient rest. The roentgenogram becomes of great 
assistance, taken after reduction. Rarely one bone of the joint for- 
mation is fractured to permit the dislocation. This is so in the hip in 
the so-called central dislocation of the femur, when the femur is driven 
through the acetabulum. Some dislocations are commonly associated 
with a near-by fracture, and the fracture is the primary injury rather 
than the dislocation. Fractures of the olecranon with dislocation of 
the head of the radius go together, and also some fractures of the 
shaft of the ulna with dislocation of the radial head. Dislocation and 



PATHOLOGY OF DISLOCATIONS 105 

fracture of part of one bone occurs \u dislocations of the elhow, for 
example, fracture of the humeral condyle or the coronoid of the ulna 
being- complications. The most serious complications of dislocation 
and fracture of the })art dislocated is seen in the ball-and-socket joints, 
particularly the shoidder. As mentioned elsewhere, INIr. Robert Jones 
said some years ago that he had over forty roentgenograms of this 
condition. I have found it a rare complication in looking over hun- 
dreds of shoulder fractures. The usual place of fracture is through 
the surgical neck, rarely through the anatomical neck. Difficulty in 
reduction lies in exerting a reducing pull on the head fragment, which 
has been largely deprived of ligamentous attachments. There are 
some successful reductions by manipulation; most are operative. 
(See Fractures of the Neck of the Humerus.) 

2. Bloodvessel injury rarely complicates dislocation. The vessels 
most often concerned are the brachial artery and vein or the popliteal 
vessels, and dislocations with great displacement are the cause. The 
tibial arteries have been injured in ankle dislocations, and in my 
case of dislocation of the tarsal scaphoid the dorsalis pedis artery was 
injured in its middle and inner coats, and its lumen was obliterated. 
In dislocation we do not find sharp or rough bony projections, which 
would tend to injure bloodvessels. The head of the humerus and the 
femur are round and smooth and do not rupture the vessels. At the 
shoulder the head of the humerus may tear the artery or vein or 
injure the inner coats of the artery so that a traumatic aneurism 
develops at once or within a few days. Gangrene of the arm may 
follow. Many of the bloodvessel complications of dislocation really 
follow efforts at reduction, especially if the time elapsed between 
injury and treatment has permitted adhesions to form between the 
ligament tags about the bone head and the vessels. Pow^erful traction 
or a fulcrum supplied by the surgeon's foot in the axilla may cause 
vessel rupture. 

The symptoms of injury of large vessels are those of concealed hem- 
orrhage. Fast pulse, shock, and paleness are prominent. At the site 
of dislocation a hematoma may form at once, which pulsates at first 
but gradually becomes tense and hard. If the axillary artery is rup- 
tured, the radial ceases to beat, but it may also be affected by press- 
ure on the axillary from a venous rupture. When the blood tumor 
is found well developed it is impossible to tell which vessel is injured, 
unless by some chance there remains a slight pulsation in the per- 
ipheral arteries, indicating that the arterial trunks retain continuity. 
Rupture of part of the vessel coats, leaving the adventitia leads to 
a more slowly growing tumor mass. This causes enlargement in the 
axilla, which may be mistaken for abscess or enlarged glands. Great 
care must be observed in cutting into such swelling about joints where 
there exists a previous history of trauma or dislocation. Dislocaticm 
may have been reduced either by a surgeon or spontaneously, the 
tumor mass causing symptoms later, possibly under the care of 
another surgeon. 



166 DISLOCATIONS 

3. Nerve complications are divided into three classes: (a) Trau- 
matic neuritis which may occur without dislocation. Nerves may 
be contused or stretched by the dislocated bone and their impulse- 
conducting power temporarily abolished. They may be stretched, and 
hemorrhages into the sheath or between the axones may act to abolish 
transmission or to cause degeneration and subsequent paresis. 

(6) Compression of nerve trunks between two bone surfaces by 
callus or by organized exudate and scar tissue. This is seen at the 
shoulder, elbow, and knee, especially about the head of the fibula, 
and a few other points. From the character of their cause these changes 
are generally late. 

(c) Rupture or avulsion of a nerve or several trunks from the spine, 
as in dislocations at the shoulder. These are relatively uncommon 
and are often overlooked at the time of injury. The motor and sen- 
sory distribution in an extremity should be thoroughly tested after 
reduction of all dislocations. 

The symptoms of nerve complications depend on the class in which 
they may lie. If a nerve or trunk is completely ruptured, there is 
complete permanent loss of motor and sensory power in its distribu- 
tion. This is permanent unless plastic repair. is performed. In the 
first class symptoms of pain, numbness, sensory and motor disturb- 
ance of varying degree are usually present. At first these are not 
marked. They gradually increase, especially if caused by pressure of 
misplaced bone ends which are not reduced. Traumatic neuritis 
tends to reach a culmination of its manifestations within six weeks, 
after which a progressive improvement begins. 

4. The abdominal viscera may be injured by dislocation of the pelvic 
bones. The bladder is particularly prone to rupture. Central dis- 
location of the femur into the pelvic cavity likewise causes injury, 
and the spinal cord may be damaged when the vertebrae are dislocated. 
The esophagus and trachea have been opened or severely compressed 
by dislocation of the sternal end of the clavicle behind the sternum or 
the cornu of the hyoid bone. (See the chapter on these subjects.) 

5. Open dislocations, especially those opened from within by tear- 
ing or pressure of the dislocated bone, are rare. The fingers are some- 
times wrenched and pulled loose by an open dislocation which rup- 
tures a phalangeal joint and tears away most of the soft parts covering 
it. These injuries result from violence which catches and holds the 
finger, or from sudden, sharp blows like that of a swiftly moving ball 
striking the end of the finger. Open dislocations of the larger joints 
are caused by extreme violence, generally "accompanied by secondary 
twisting or wrenching after the dislocation has occurred. The skin 
opening may be produced at once by the outside force or from the 
bursting through of the dislocated bone head. These wounds are 
similar to those of open fracture, but in dislocation we have a joint 
surface exposed to outside contamination. As a rule, joint surfaces 
have less resistance to infection than bone, especially joint surfaces 
which have been suddenly snatched from a normal condition and 



COURSE AND REPAIR OF REDUCED DISLOCATION 167 

rudely opened to outside infections. Joints which have been trauma- 
tized and in the subsynovial layer of which a resistance has developed 
by a slow, low-grade inflammation have greater resistance. Open 
dislocations often lead to serious joint and bone infections. Amputa- 
tions or complete excision of bones for necrosis and osteomyelitis 
follow. This is true in every case of dislocation of the astragalus that 
I have seen. 

In the large joints the possibility of infection is great. Infection 
leads to pyarthrosis and probable destruction of joint surfaces, osteo- 
myelitis, drainage, ankylosis, and possibly amputation. The prog- 
nosis is also grave, because these injuries are caused by great violence. 
Secondary opening may follow from pressure of the bone on the soft 
parts causing ischemia and local gangrene with sloughing. 

Treatment of open dislocation is conservative. An effort is made to 
minimize infection by gentle cleansing or irrigation, and the dislocation 
is reduced. The wound is partly closed, drainage into an aseptic 
dressing being provided for. When infection starts, free drainage 
is indicated at once. If that fails to quiet the suppuration, resections 
of the joint or amputation are left. 

Course and Repair of Reduced Dislocation. — As in the pathology 
of all traumata on living tissue, the repair rests on the extent of 
primary injury and the course of the dislocation after reduction 
of the periarticular structures. The usual course of reduced disloca- 
tion is simple, and the ultimate result is excellent functionally. The 
initial swelling is not great, especially if reduction has been accom- 
plished soon after displacement. Pain and loss of function are also 
temporary, if the joint is given rest for a proper period that a normal 
surface condition may be regained, and the rupture of the capsule 
be permitted to heal. The amount of motion following dislocation 
is often left to the patient after a few days' immobilization, because 
no motion will be indulged in which produces pain or swelling inter- 
fering with use. A dislocated shoulder is put in a simple arm sling, 
and when the patient discovers that motions of use are painless and 
free they are indulged in to that range. Slowly full function is estab- 
lished. In some cases the periarticular structures have suffered con- 
siderable laceration, or there is greater hemorrhage, or some of the 
minor complications have taken place. Under these circumstances 
pain and swelling persist much longer, there is an inflammatory reac- 
tion, and rarely suppuration and abscess formation are present. The 
greater the inflammatory reaction the greater the restriction of motion 
will be from contractions of organized exudate about the joint, adhe- 
sions within the joints, and the binding of the periarticular muscle 
and tendons. 

Secondary loss of function and pain may follow a course after reduc- 
tion which appeared to be simple and satisfactory. This is com- 
parable to an obscure and slow osteo-arthritis in which the changes 
have followed after the trauma of dislocation. 

The course of open dislocations varies. Many of them which are 



168 DISLOCATIONS 

handled asc})ti('ally and j)r()niptly rednced lead to a primary healing 
of the soft parts. Others are infected, and all grades of suppuration 
in soft i)arts, joint, and bone result, with the consequences previously 
mentioned. The other complications involving bloodvessels, nerves, 
and bone change the course. Fracture especially leads to much loss 
of joint motion, through the misplacement of fragments or the forma- 
tion of restricting callus. Fracture dislocation of the head and neck 
of a bone must first be considered as fracture, and efforts must be 
directed toward reduction of the fragments, which implies an inci- 
dental reduction of the dislocated head. Some fractures of an articular 
edge or an apophysis lead to irreducible and recurrent dislocation, a 
condition which may last during the patient's lifetime. The prognosis 
is good as to life, but if reduction is difficult, the chance for complete 
return of function is affected. The various complications, the joint 
involved, and the time after injury at which reduction is attempted 
all influence the reducibility. 

The repair of dislocation must accord with the course. Disloca- 
tions undergoing repair after reduction are seldom seen by the surgeon, 
as no indication exists for open operation unless there should be sup- 
puration, and then drainage alone is done. Most of our pathological 
knowledge comes from operations on recurrent or old unreduced dis- 
locations. Rarely autopsy is performed on persons who have suffered 
traumatic dislocation and had an exitus during the course of healing 
of the dislocation. We expect local hemorrhage about the structures 
which have been stretched or torn by the luxation. This is seen 
clinically in the large ecchymoses which spread by gravity from 
shoulder dislocations. The joint may be filled with blood-clot or 
there may be but a small mass sealing the capsular tear. This tear 
as well as lacerations of other structures about the joint must heal 
by connective tissue, which cicatrizes and produces a scar. If the dis- 
location has been extreme, with any of the complications described, 
the resulting healing is an exaggeration of the simple process. The 
torn capsule may become adherent to vessels, muscles, or bone. The 
capsular structures become thickened as a result of violent attempts 
at reduction or motions indulged in before simple healing has taken 
place. Insufficient immobilization or early attempts to free the joint 
by painful passive motion have the same effect. All such adhesions 
cause restriction of motion. Infection and suppuration with their 
train of consequences are , rare. The other complications involving 
fracture, nerve and bloodvessel injury have been enumerated and 
will be considered specifically under each dislocation discussed. 

Recurrent and Old or Unreduced Dislocations.— Recurrent or 
habitual dislocation of the large joints are rare. They may follow an 
ordinary traumatic dislocation, but usually they are associated with 
some of the complications of luxation. Paralysis of muscle groups, 
laceration and incomplete repair of muscles important to the integrity 
of the joint, and acquired laxness of the capsule promote a tendency 
toward recurrence. A slight trauma or a position of the part which 



RECVRREXT AXD OLD OR VXREDVCED DISLOCATIOXS 169 

throws strain on a weakened or lax side of the retaining capsule is 
all that is needed to permit the bone to slip out of the joint. The 
oftener this luxation occurs the more easily it luxates on subsequent 
occasions. The result is that the patient gradually restricts the use 
of the joint until all its motions remain within a safe limit, and it is 
only a rare unguarded movement during excitement that will result 
in another luxation. The recurrence may become so frequent that 
all pain and tenderness are lost, and the patient learns to make a 
reduction by directing his friends or by executing manipulations 
himself. On the other hand, especially in the shoulder, each recur- 
rence may be as painful as the original luxation, probably on account 
of pressure on nerve trunks. 

The pathology depends on the character of the original dislocation. 
Recurrence to the extent of causing an habitual condition is rare in 
normal joints. If the primary luxation has affected a joint poorly 
developed from the standpoint of its articular surface or of the enclos- 
ing ligaments, an unfortunate second trauma may start the articula- 
tion on the path of habitual luxation before complete healing has 
time to take place. Usually the rent in the capsule has not closed, 
or it has closed to leave a weak spot which bulges, or for a long time 
a joint effusion persists which also aids in distending the capsule. 
The loss of small pieces of bone which maintain a guarding edge of 
the articulation also favors an easy recurrence. If a small bone 
mass is split off and its periosteal attachment is torn, it gradually 
undergoes absorption and disappears, the edge from which it has been 
torn becoming rounded off. Recurrent dislocations which are based 
on paralyses are usually considered a matter of orthopedic treatment. 

Old dislocations unreduced are serious problems and have a path- 
ology quite distinct. Just when dislocation becomes an old disloca- 
tion which it is impossible to reduce by manipulation, depends on the 
individual case. Some joints become irreducible very quickly, depend- 
ing on their size and the strength of muscles which pass over them or 
which maintain luxation by contraction. The local pathology about 
the joint also has an important bearing on the status of the luxation. 
Usually a joint begins to get into the class of old dislocation after 
four or five weeks, and before attempts at reduction are made the 
local conditions should be carefully ascertained. I have reduced 
>houlder dislocations five weeks old with no difficulty and in one three 
weeks out of joint I fractured the humerus by gentle manipulation. 
Reductive attempts should be without undue force and should aim 
to establish the possibility of the reducibility of the luxation without 
trying to accomplish reduction in spite of serious obstacles. If reduc- 
tion cannot be made by safe procedures which will cause no additional 
damage, the case must be considered an operative one. 

The pathology of unreduced dislocation concerns the capsular 
ligament and synovia and the soft parts surrounding the joint and 
bone with its cartilage. The first changes in the capsule are identical 
with those of dislocation which is reduced. There is capsular tear, 



170 DISLOCATIONS 

hemorrhage and extravasation into the joint and surrounding tissues, 
and in some cases small fractures, periosteal stripping, and cartilage 
injury. The dislocation remains unreduced because it is not recog- 
nized, or a complicating fracture exists, or because the attendant 
is unable to make a reduction under the circumstances in which 
the patient is treated. The fact that the dislocation is not reduced 
leads to a prolongation of the local reaction induced by the trauma, 
and secondary changes follow, caused by the changed relationship 
of the parts and efforts to create in the new position a surface which 
will take up the function of a joint. The tissues about the dislocated 
head become filled with extravasated blood from the lacerated vessels 
of torn capsule or muscles, pressure is exerted on all surrounding tis- 
sues, and the bruised parts are gradually infiltrated with small round 
cells. Blood is absorbed, the muscles are repaired by the granulation 
cells, and the whole area is surrounded by a fibrous capsule. Within 
the new fibrous capsule lies the displaced bone head. It is usually 
more or less free, permitting some of the ordinary movements of the 
joint, although they are greatly restricted, and is not adherent unless 
bare bone has been exposed by stripped periosteum and apophyseal 
splinters. The connective-tissue cells lining the fibrous capsule flatten, 
and by metaplasia assume the shape and appearance of cells lining 
a synovial cavity. The transition is similar to that in the formation 
of new joints when fibrous tissue is used in surgical arthoplasty. The 
original capsule may be continuous with the newly formed joint 
because, as previously mentioned, it is rarely completely torn off. 
Under some circumstances the bone head escapes through a tear in 
the capsule which closes valve-like around the neck, and the natural 
capsule remains more or less intact, minus the bone head, until sec- 
ondary changes follow. These changes are obliteration by adhesions 
resulting from the trauma and the pressure of the surrounding parts 
on a surface no longer functionating. 

Within the new capsule may be found a small amount of fluid. This 
may be secreted by regeneration of some of the synovial surface cells 
which have been carried into the lacerated area. 

The outer surface of the fibrous capsule is usually adherent to the 
surrounding lacerated tissues. These are muscles and nerve and blood- 
vessel sheaths, and as the connective tissue ages this adherence becomes 
very firm and by its contracture may further restrict the joint move- 
ments or cause changes from pressure on the nerves and vessels. 
On account of the new position of the bone and the different muscle 
balance consequent upon it, the muscles crossing the joint or inserted 
in its vicinity undergo shortening or atrophy. This fact may be 
illustrated by a dislocation forward of the humerus at the shoulder. 
The great pectoral muscle, attempting to functionate, has to shorten 
its fibres, because the insertion in the displaced humerus has been 
brought nearer the origin on the chest. The muscle may also undergo 
some atrophy on account of its restricted use. The deltoid muscle 
may be stretched by the new position of the humerus, but as weeks 



RECUBREXT AND OLD OR UNREDUCED DISLOCATIONS 171 

pass and the dislocation remains unreduced and abduction of the 
arm is greatly restricted, this muscle undergoes an atrophy. 

The coincident bone and cartilage changes must also be understood. 
These can be discussed in the order of their occurrence as the luxation 
becomes old. Chips of bone broken off articular rims or raised up by 
stripped periosteum may proliferate or become absorbed, according 
to the retention of their blood supply and the amount of proliferative 
irritation they are subjected to by joint movements. Small exostoses 
may grow along the stripped periosteum or out into the fibrous cap- 
sules. A thick layer of new bone may be deposited beneath a raised 
periosteum and act as a restrictor of motion in the new false joint. 
A strong bridge of bone may be laid down along a periosteal shred to 
connect the two bones of the joint. That portion of the dislocated 
head or neck which comes to lie in contact with the other bone forming 
the joint is subjected to an unnatural pressure, the periosteum is 
eroded, and some absorption takes place in the area, so that a depres- 
sion is formed. This is enhanced by an irritative proliferation at the 
edges which are attempting to offer support and stop the pressure, 
a slight ridge being built up about the absorbed part. 

The whole shaft of the displaced bone also undergoes structural 
change similar to that following fracture. By means of serial roent- 
genograms taken week by week, as a dislocation remains unreduced, 
changes in the osseous structure can be seen. The bone becomes more 
transparent to the ray, the lamellae are thinner, and there is undoubt- 
edly a disturbance in the calcium equilibrium of that bone. These 
changes are in accordance with Wolff's law and arise from the altered 
and incomplete function of the luxated bone. These changes offer a 
partial explanation of the ease with which bones in old dislocations 
are broken when subjected to manipulation, and constitute a clinical 
point of importance. The cartilaginous surface of the head and the 
joint from which it has been removed undergo slow changes. When 
articular cartilage has been stripped or torn from the surface of the 
head, we may expect to find bone regenerated, a fact which is verified 
by examination of old dislocations at operation and autopsy. If the 
cartilage has not been injured, it tends to remain intact for an indefi- 
nite period. The joint surface slowly fills in with cartilage and soft 
bone and its contour becomes lost. This material ultimately ossifies 
and is cemented to the joint surface so firmly that it can be only 
removed by a sharp chisel. The elbow reacts more in this respect 
than other joints commonly dislocated, and the bony mass makes 
reduction impossible without a complete removal and reformation 
of the joint surfaces. The growth does not demand a great length of 
time. I have seen it become very extensive within three months 
after dislocation. 

The final change about the unreduced bone head represents a natural 
reaction of the tissues to adapt themselves to new conditions and to 
aid function as much as possible. When use is attempted and the 
dislocated bone moves and the new joint begins to functionate within 



172 DISLOCATIONS 

its restrictod limits, the neighboring bone structures are stimulated 
to build up a new cavity for joint purposes. This is best demonstrated 
in hij) dislocations when the femoral head rides on the ilium. From 
the ilium bones develop, buttressing edges of which tend to form a 
new acetabulum about the head and furnish some stability to the 
new capsular ligament. These changes are all in response to functional 
use and are like those appearing in bone transplants which grow and 
assume the shape of the bone they replace as function progresses. A 
transplant inserted into the upper end of the humerus, one end lying 
free in the glenoid, will take on the shape of the former humeral head 
if it is used and the muscles are attached. The growth is a pure 
osseous structure, and is very firm, so that its removal requires cutting 
with sharp chisels. The process may become excessive and spread 
out into the new joint capsule enclosing the head and gradually pro- 
duce a complete ankylosis. 

Symptoms, Signs, and Diagnosis. — The symptoms and signs of 
dislocation are as closely interwoven as those of fracture, and they 
will be considered in the order of relative importance without an 
attempt to separate objective and subjective findings. The examina- 
tion of the patient must be thorough and comparative. Not only 
must the joint which is complained of be carefully subjected to tests 
and local manipulation, but the corresponding normal joint must be 
used as a basis for comparison. This means that the patient should 
be exposed sufficiently to permit the free inspection of the joints con- 
sidered, and every precaution must be taken to eliminate natural 
peculiarities and attempts at malingering. Diseased conditions which 
affect joints must be borne in mind constantly. The different arthrop- 
athies peculiar to diseases should be remembered. Tabes particularly 
is a stumbling-block. 

The condition of bloodvessels and nerves in the limb should be 
ascertained and a written record made. This record is of assistance 
to the surgeon or a consultant, if the dislocation remains unreduced 
or complications appear which involve the enervations or blood 
supply. If the nerve supply to arm and hand is intact immediately 
after dislocation of a shoulder, so that the usual motions of the wrist 
and hand are possible, the surgeon can, if paralyses appear later, elimi- 
nate avulsion or rupture of branches of the brachial plexus and can 
attribute them to pressure or secondary causes. The same precaution 
is taken in regard to circulation. Radial pulse is searched for and its 
condition noted. These same records should be made after reduction 
to establish any causative relation between attempts at reduction and 
subsequent evidence of injury of these structures. (See History.) 

Examination must determine the position of the head of the bone 
to the satisfaction of the surgeon. In most cases the position is both 
visible and palpable when the limb is manipulated. In others swell- 
ing, effusion about the joint, much adipose tissue, pain, or lack of 
cooperation by the patient may prevent definite information. The 
final expedients consist in obtaining a roentgenogram and in admin- 



SYMPTOMS, SIGXS, AXD DIAGNOSIS 173 

isteriiig a general anesthetic for diagnostic purposes. The same 
statement made in regard to the use of anesthesia for diagnosing 
fractures should be made here. It should be employed in all doubtful 
cases, but when it is used its aid must also be extended to cover treat- 
ment, which the surgeon must be prepared to apply at the same 
sitting, regardless of the character of procedure needed. The roent- 
genogram is valuable in old dislocations for demonstrating the amount 
of secondary change about the joint. Fresh dislocations are not so 
often subjected to the rays, because diagnosis is not difficult and the 
patient's distress demands immediate reduction. Certain complica- 
tions, especially accompanying fracture, are shown by the roentgeno- 
gram, and for that reason it is often the best procedure to have a 
picture before reductive attempts, in order to avoid unsuccessful 
manipulations which may be harmful on account of the fracture 
present. 

A history of some sort is always obtained before diagnosis is ven- 
tured. The kind of violence and the position of the patient and the 
limb are inquired into. The character of the pain and subjective 
sensations of crepitus are often valuable to the surgeon. One must 
also be sure whether the joint has ever before been dislocated and 
whether the dislocation is one which can be caused voluntarily. Frac- 
ture is the first condition to be eliminated in differentiation, and the 
history will often help, especially if there has been a previous injury 
of one kind or other. In case of any doubt the roentgenogram and 
examination under anesthesia will be decisive. Usually one can pal- 
pate the dislocated ends sufficiently well to rule out fracture of a neck 
or shaft, but not well enough to disprove the smaller fractures of 
bone edges. Frequently also the swelling and extravasation are 
prompt enough to mask characteristic deformity, and any surgeon 
may be unable to make a definite diagnosis without the aids mentioned. 

Deformity is apparent in most dislocations, and it is quite charac- 
teristic, as is also the patient's position. The location of the bones 
forming the joint is abnormal to a varying degree, and the exact 
position can be made out by palpation and a little manipulation. 
Most dislocations are quite rigid, and swelling does not appear at 
once to mask the preliminary. findings. After a few hours the extrav- 
asation may fill out depressions or cause so much periarticular dis- 
tention that the evidence obtained by inspection is altered. Some 
deeply .seated joints are difficult to examine on account of the over- 
lying mass of soft parts. When this condition is augmented by a 
hemorrhage into the tissues, recognition of the character of the injury 
is almost impossible through inspection and palpation alone. At the 
knee and elbow, dislocations are relatively easy to recognize by deform- 
ity. At the ankle, shoulder, and hip they are more difficult. The 
examination must be steadily urged after the patient's confidence is 
won. The head of the bone must Ix^ sought after one notes the 
j)ositi()n of the shaft or other well-known joints of the bone which 
furnish landmarks indicative of the usual location of the head. Slight 



174 DISLOCATIONS 

movements of the shaft are transmitted to the head unless there is 
fracture. If these movements are lacking in the space where the 
head normally lies, and are found in an abnormal position which 
other bony points indicate that the head has shifted to, one can be 
sure dislocation is present. 

Shortening and lengthening deformity are also signs. Either one 
may be apparent and not real when measurements are used. The 
rigidity of the limb and the muscular spasm do not permit the sym- 
metrical placing of corresponding limbs, and measurements fail to 
give exact information. The same precautions in regard to normal 
varying length of limbs given in the chapter on Fracture of the Femur 
must be used in all dislocations examined in this manner. 

Loss of mobility and function are also important symptoms. These 
go hand-in-hand, the function depending on the changed mobility. 
Some complete dislocations retain a surprising amount of function 
and motility in the part, and the patient may be unaware that the 
joint has been disrupted. The subluxations are usually of this char- 
acter, and function except in one or two special directions may be 
normal. Usually if function is little interfered with, there is also 
pain at this limit, and relief is sought on that account. 

Loss of mobility depends on the joint dislocated. All typical luxa- 
tions assume a position which is characteristic and is described under 
each dislocation discussed. When the bone head is thrust into an 
unnatural position and remains there, the limb axis changes, and a 
new centre for the arc of motions is established. The untorn portion 
of the ligaments is put on a stretch and fixes the dislocated head so 
that it cannot be moved farther away from their attachment without 
their rupture. Pain and muscle spasm also inhibit mobility. Muscles 
have less influence than the untorn, non-elastic ligaments, because 
their length has been altered by the new position and their contractive 
power is overbalanced. Their influence can be eliminated by the 
administration of anesthesia, but the ligamentous limitation cannot 
be so overcome, and the loss of mobility in dislocation is present in 
unconsciousness. This furnishes a basic differentiation between 
fracture and dislocation which is open to very few exceptions. Frac- 
ture usually presents excessive mobility, except in the few instances 
when the part is held more rigid, a reflex protective measure of the 
body on account of pain. A few dislocations also vary to permit an 
unusual amount of motion. They are accompanied by complete 
tearing of the capsule and generally by fracture. 

Pain and Crepitus. — Sharp pain is present in a joint which suffers 
traumatic dislocation. It may be acute enough to cause collapse 
and vomiting. This pain continues for a few hours on account of the 
pressure at the joint and the extravasation, together with the stretch- 
ing of the lacerated tissues. Usually it subsides within twenty-four 
hours to a bearable state, but is easily provoked by efforts at use or 
by manipulation. Tingling and burning pains or numbness referred 
distally to the dislocation indicate pressure on nerves by the head 



TREATMENT OF DISLOCATIONS 175 

of the bone. If this disturbance with muscular paralyses comes on 
late in the course of an unreduced dislocation, it may be surmised 
that a nerve trunk is included in scar tissue. Crepitus is sometimes 
found in dislocation. It is different from the sharp clicking of frac- 
tured bone surfaces and is probably caused by the neck of the dis- 
located bone moving against the edge of the opposite bone. A dis- 
located tendon, hke the biceps tendon at the shoulder, may produce 
a sensation simulating crepitus when the arm is manipulated. The 
softness of the crepitus and the absence of other signs of fracture help 
differentiate the two conditions. 

Treatment. — From the remarks made on etiology and mechanism 
of dislocation, it is evident that leverage action plays the most impor- 
tant part in causing traumatic dislocation, and that treatment which 
primarily aims to return the misplaced bone to its former position 
must reverse in part the conditions existing during the operation of 
the cause. The capsular ligament is seldom completely torn, and it 
is the traction of its untorn fibers which has much to do with holding 
the bone out of place. Efforts to reduce are divided into traction 
and manipulation, 

1. Traction is the oldest method and is now little used, except in 
combination with manipulation. Force was applied manually in the 
long axis of a limb by the surgeon and his assistants, counter-pull 
being made on the trunk by one of them. In cases of hip dislocation 
mechanical extension was often used by means of a band around the 
leg and foot attached to the pulleys. Considerable force could be 
exerted to pull the head of the dislocated bone down toward its socket, 
and the surgeon then made pressure or manipulation on the head to 
force it into place. The force used in this type of reduction was so 
great that the bone was dragged back in spite of the resistance of untorn 
ligaments, and often damage additional to that of the original dis- 
location was done by the laceration of these remaining intact struc- 
tures; nerves and bloodvessels were frequently torn; there was much 
shock, and suppuration resulted in the joints. The method did not 
take the mechanism of the cause of dislocation into consideration and 
was based on force rather than pathological knowledge of the usual 
tissue conditions about the joint. Often it succeeded with little 
difficulty, because the secondary displacement of the limb had not 
taken place and the head of the bone was pulled in the right direction 
to reenter the socket through the tear in the capsule. The capsule 
may also have been so widely torn that the head could be drawn into 
place without opposition. 

Continuous traction by the attachment of India rubber bands or 
adhesive straps with weight and counter-extension is also an old 
method modified from the means of direct forcible traction. This 
method attempted to tire out the muscles about the shoulder, for 
instance, in dislocations involving that joint. A weight of twenty 
pounds was applied on a pulley with the arm in as mucli abduction 
as could be obtained, and after a few minutes when the contracted 



17() DISLOCATIONS 

muscles relaxed the head approached nearer the glenoid, the long- 
axis of the arm assumed a more normal direction, and the reduction 
could he completed hy the surgeon giving a sudden additional jerk 
or hy pressing the humeral head at the shoulder into the socket. At 
the present time anesthesia accomplishes the relaxation with no pain 
and more quickly. Continuous traction was also made by the use of 
the unsupported weight of the limb. The patient lay on a table or 
bed in a manner which permitted the limb to hang and pull by its own 
weight until the muscular contraction was overcome and the head 
slipped into place. (See Dislocation of the Humerus.) 

Manipulation has become the method of choice in treatment of 
traumatic dislocation. It is based on a better knowledge of the 
immediate pathology and seeks to restore the bone head by leverage 
which utilizes remaining ligaments as a fulcrum, does no additional 
lacerating damage to the capsule, and attempts to reenter the joint 
via the tear of exit. Each joint necessitates its own manipulations 
and a general statement only can be given here. Attempts to reduce 
by traction made in opposition to the restraining pull of the persisting 
ligaments are not performed, but the ligament is taken advantage 
of by moving of the limb in the direction in which this pull is exerted 
and by subsequent leverage using this attachment to help guide the 
head into position. The manipulations also aim to reopen the tear 
in the capsule so that the head easily slides back. Some traction is 
necessary that the spastic contraction of muscles may be overcome 
unless an anesthetic is used. Many luxations are reduced with ease; 
others present obstacles and demand repeated attempts with close 
attention to the detailed requirements for the joint under treat- 
ment. 

An obstacle to reduction of recent uncomplicated luxation is found 
in the pain present, which results from the capsular and tissue damage 
or from nerve pressure. The pain is increased by manipulative efforts, 
and fear of it induces muscular contraction and lack of cooperation 
by the patient. Swelling about the joint from the extravasation may 
also hinder reduction, just as it interferes with reduction and its 
maintenance in fracture. If the fascial envelope about the joint is 
intact, the extravasated blood distends it in a transverse diameter, 
shortening the longitudinal, and preventing manipulative efforts 
to bring the head back into the joint. For that reason it is best to 
reduce a fresh luxation as soon as it is seen, before the swelling has 
reached a maximum. If it does furnish a real obstacle to reduction, 
the surgeon may wait a few days for its subsidence under cold appli- 
cations, or give an immediate anesthesia. The subcutaneous fat of 
obese persons may offer an obstacle to reduction inasmuch as it 
interferes with the proper manipulation. 

The role played by the ligamentous and capsular structures in 
obstructing reduction depends on the pull of the untorn portion, the 
site of the capsular tear, and the interposition of flaps or shreds between 
the head and the joint surface. Manijnilation applied on a basis of 



TREAT ME XT OF DISLOCATIONS 177 

the pathology m the mjiired joint tries to utilize this pull as outlined, 
but the tear in the capsule may be of a character that brings a flap 
down over the joint surface and shuts the head out of the socket in 
spite of all eft'orts to spread it open that it may receive the bone. 
This t^-pe of dislocation is also found in the one in which the head is 
thrust completely out through the capsular tear, and the capsular 
slit closes completely behind it around the shaft. Dislocations caused 
by direct violence with great laceration or complete tearing of the 
capsule are very mobile, and the absence of ligamentous restraint 
permits an easy reduction by direct traction. The two types can be 
differentiated by the greater mobility in the form caused by direct 
violence and the reduction may be quickly performed without much 
manipulative effort. 

In some cases of dislocation of the smaller joints a muscle may be 
penetrated, or a tendon may T\Tap itself about a dislocated bone end 
and obstruct reduction. Concomitant fractures of the neck or shaft 
of a bone, small fragments split off the cartilage or the other bone 
forming the joint, also offer obstacles to reduction. 

The complications of reduction or attempts at reduction are divided 
into immediate and delayed. This division of complications is selected 
because it fits pathological conditions as we now understand them and 
does not depend on irrational treatment. Many of the complications 
of forcible reduction of dislocations which were common twenty-five 
years ago are seldom seen at this time on account of prompter reduc- 
tion, often under anesthesia, the checking use of the roentgenogram 
afterward, and a more intelligent early operative interference. The 
complications and dangers incident to general anesthesia, the remote 
sequelae of surgical procedure which occur after any operation, and the 
unforseen troubles which arise after traumatic accidents cannot all 
be attributed to dislocation alone. ]Many of these conditions have 
been discussed fully in the chapter on the Pathology of Fractures, and 
only those which are of special interest in connection with dislocation 
will be described here. 

The immediate complications of reductive efforts are injury (1) to 
the bloodvessels, _ (2) injury to nerves, (3) fracture, (4) rupture of 
muscles, fat embolism and sudden death, (5) avulsion of a limb and 
(6) damage to the skin. Delayed complications consist in late mani- 
festation of injury to bloodvessels, nerves and lymphatics, resulting 
in paralyses, persistent edema or late gangrene, infection and sup- 
puration in the joint, and ankylosis. 

Injury of bloodvessels in dislocations which are promptly reduced 
is rare. Confusion arises as to the cause. Probably over half are 
caused by the trauma of dislocation and the symptoms do not appear 
until just after the early reduction. For that reason the condition of 
the distal arterial supply should be ascertained in every case before 
efforts at reduction are undertaken. These injuries occur more fre- 
quently in elderly people, especially those with stiffened arteries, 
and in cases where repeated and forcible efforts have been made at 
12 



178 DISLOCATIONS 

reduction. Ilessniann^ reported rupture of an axillary artery in a 
seventy-two-year-old man, and Korte^ reported 4 cases and made 
a collection of over 40 others. Most of the main bloodvessel injuries 
occur at the shoulder. At the knee, elbow, ankle, and hip they are 
rare, and the recent literature of dislocations contains little reference 
to them, on account of change in methods of reduction, and the greater 
frequency of open operation. Wild and repeated efforts at reduction 
should be avoided, especially when the patient is under anesthesia. 
The primary injury of the dislocation may partly tear through the 
wall of a large vessel; a traumatic aneurism with a sac may slowly 
develop and the vigorous movements of reduction cause it to burst. 
The dislocation may tear off small branches of a main artery and lead 
to the formation of a slowly forming blood mass. This may be mis- 
taken for abscess and be incised. In old dislocations, adherence of 
ligaments or bone to the vessel wall causes a tearing when violent 
efforts are made to free the structures. Dislocations of long standing 
are accompanied by shortening of the vessels or increased local rigidity. 
Adherence is more likely to injure the thin-walled vein than it is the 
artery. Hyperabduction of an arm after many weeks of confined 
position in dislocation easily injures the vessels. Bone pressure in 
an abnormal position against a large pulsating artery may gradually 
weaken the vessel wall, and reductive force adds the finishing touch. 

The symptoms of immediate injury of important bloodvessels dur- 
ing reductive attempts are pain, shock, formation of a rapidly grow- 
ing, diffuse tumor near the dislocated joint on which the efforts have 
been made at reduction. Almost all the reported cases concern the 
shoulder and the axillary vessels. The tumor is fluctuating, occupies 
the axilla, even bulging out behind, and over it may be heard or felt 
a bruit. The distal pulse may or may riot disappear. If the patient 
survives the rupture, a wide-spreading ecchymosis appears on the 
chest and shoulder. Some ruptures cause death within a short time 
before any treatment can be attempted. When a small vessel is 
injured, the mass of hemorrhage may be of slow growth and reach a 
stationary point. This rupture is caused by the immediate effects 
of the efforts at reduction, but its appearance may be late. Theoreti- 
cally the surgeon would expect to differentiate between arterial and 
venous rupture by the color of the distal part, the presence or absence 
of pulsation in the distal vessels, and the bruit in the aneurismal mass. 
Practically this is difficult or impossible to do. Though the main 
injur}' may be venous, the mass may transmit the underlying arterial 
pulsation, or a small arterial branch may be ruptured nearby and 
lend its pulsation by hydrostatic pressure to the whole liquid tumor. 

The treatment of vessel injury depends on its gravity. If a slowly 
growing mass becomes evident after reduction, pressure and cold 
may stop its progress. Arterial rupture is very serious at the shoulder, 
and the surgeon must decide whether it is better to operate early in 

' Miinch. med. Wchnsohr., 1905, No. 42. 
2 Aroh. f. klin. Chir., xxvii, 631; ibid., Ixvi. 



TREATMENT OF DISLOCATIOXS 179 

the face of a small blood tumor, tie the vessel, and attempt its repair, 
or wait until collateral circulation has had an opportunity to enlarge 
and then close the main vessel by ligature. INIodern surgery leans 
toward early operation with repair of the lateral wall of the vessel, 
transplantation of an autogenous piece of vein, or endo-aneurismor- 
rhaphy. If these fail and gangrene ensues, amputation is the only 
recourse. 

Injuries to nerves are not common during reduction of recent dis- 
locations. ]Most instances occur at the shoulder on account of the 
proximity of the brachial plexus to the shoulder region. The circum- 
flex nerve alone or whole branches of the brachial plexus may be injured 
from bone pressure or tearing adhesions. At the elbow, the ulnar, 
median, and radial nerve may be involved, particularly in dislocation 
of some standing. I have seen one case of injury to the ulnar and one 
of the median. In the leg, nerve complications are rare; rarely the 
sciatic has been involved in hip dislocations, and the external peroneal 
in dislocations of the head of the fibula. In these cases there is always 
difficulty in decision as to whether the nerve complication belongs 
to the dislocation or the reduction; hence the value of careful obser- 
vation before reductive attempts. 

Fracture also results as a reduction complication when unwise force 
or forced position is attempted. The neck of the humerus may be 
broken b}' leverage with a foot in the axilla. I have seen one case. 
Abduction and rotary motions may fracture the shaft spirally, as in 
one of my o^-n cases. I have also seen the lesser trochanter of the 
femur pulled out twice in efforts at reduction of dislocated hips. 
At the elbow the lower end of the humerus may be broken. On the 
whole, the accident is rare. The instances are not, however, confined 
to old dislocations. ]\Iuscle rupture is also uncommon. Muscle 
shortening following dislocation may lead to a tearing out of its bony 
insertion when extreme attempts at reduction are practised, but rup- 
ture of the belly of the muscle is practically never seen. At the 
shoulder the spinati or subcapsular muscles may be lacerated. The 
neck of the humerus will always break before the pectoral muscle is torn. 

Avulsion of a limb has been recorded as a complication of reduction. 
Guibe^ collected 49 cases. Probably most cases have underlying 
pathological changes which were not noted at the time, involving bone 
and soft parts. Syphilis, carcinoma, sarcoma, and degenerative 
changes, softening in character, may favor such an unhappy ter- 
mination. 

Skin complications of reduction consist in tearing or lacerations 
from cords used for traction, or pressure necrosis following prolonged 
constriction. Severe pressure over a block or the pressure of an 
unpadded Thomas wrench may cause skin necrosis. The use of 
mechanical traction must be guarded by heavy pads about an ankle. 
Saddler's felt is the best material. 

' Rev. de Chir., I'Jll, xliv, 581. 



180 DISLOCATIONS 

Sudden death during manipulations of reduction may be caused by 
shock, hemorrhage, emboHsm, or anesthesia. They are infrequently 
seen. If fracture accompanies the dislocation, fat embolism must 
be considered following the manipulation of the bone fragments in 
reduction. 

The delayed complications are the late bloodvessel and nerve com- 
plications, infection with suppuration, and sometimes gangrene and 
ankylosis. The bloodvessel and nerve conditions are described under 
the immediate complications. Infection rarely follows present-day 
methods of reducing closed dislocation. I have never seen a case. 
Great extravasation about a joint may cause pressure necrosis through 
the skin with secondary infection, or the trauma of reduction may 
cause the location in the joint of wandering infections from the blood 
stream. Gangrene may follow from pressure of the inflammatory 
mass, or late infection. Edema from interrupted venous or lymphatic 
drainage may persist as a late complication from reduction. Anky- 
losis partly caused by traumatization of the joint surface in forcible 
reduction, or the processes inaugurated by the dislocation may follow 
any reduced dislocation. This ankylosis may be from intra-articular 
or periarticular changes, the former being set up by irritation of the 
synovial surface with the possible aid of bacterial invasion from the 
blood stream, the latter from ligamentous contraction and the forma- 
tion of bony outgrowths from torn periosteum and wandering osteo- 
blasts. 

Operative treatment of recent dislocations is broadly indicated 
when the obstacles mentioned are not overcome even under anesthesia. 
Arthrotomy is indicated when the displacement is unusual and there 
is some interposition of muscle, fascia, or ligament. It is also indi- 
cated when cartilaginous and bone fragments obstruct, or a tendon 
is inextricably wound about the bone. A generous incision over the 
part of the joint suspected of blocking reduction is made under the 
usual aseptic precautions, and the obstacle is snipped through or slid 
over until the bone can be returned to the socket. A minimum amount 
of operative procedure is undertaken, and if the capsular rent is not 
great and does not tend to fall into the joint, it need not be sutured 
at all. An immediate arthrotomy before secondary infiltration and 
swelling is usually successful and remains clean. If swelling and 
secondary position have already occurred in the joint, it is better to 
wait a week or ten days for the absorption of the exudate and the 
resistance building of the leukocytic infiltration. The same problem 
arises as in repair of the fracture of the patella, and the immediate 
operation has as many adherents and happy results as the delayed, 
provided the skin condition and the asepsis are satisfactory. 

Treatment of habitual dislocation is at first conservative and non- 
operative. The joint is put at rest in a simple dressing for the upper 
extremity and a cast or Thomas splint for the hip and knee. The 
prolonged rest may cause a shrinking in the capsule or permit it to 
regain tone sufficient to prevent recurrence after the dressing is 



TREATMENT OF DISLOCATIONS 181 

removed. Slightly restricted function afterward, go\^erned by straps 
or elastic supports, favors a normal joint function. Operative treat- 
ment is resej-ved for the stubborn cases. I cannot see the advisability 
of injecting irritating solutions into the joint. They undoubtedly 
cause an exudation which temporarily distends the joint and but 
weakens the capsule the more. An injection followed by immob- 
ilization for a period long enough to allow absorption of the exudation 
and retraction of the capsule might lead to an ankylosis. Irritating 
injections of formaldehyde in glycerin which are used for joint infec- 
tions, produce a marked reaction, but do not lead to restriction of 
joint motion. It would seem more rational to employ periarticular 
injections of tincture of iodine or other solutions. The inflammatory 
reaction set up with immobilization should cause a cicatrization of 
the pericapsular fibrous tissue and ligaments and subsequently 
strengthen the joint. These methods are used clinically with success, 
especially in the jaw, shoulder, and clavicle. Stimson reported two 
cases of habitual clavicular dislocation cured by periarticular injections 
of alcohol. 

Operative treatment aims to shorten the capsule by plication and 
to tauten by transposing of muscle and fascial flaps or by shortening 
of isolated muscles or groups of muscles which control the joint motions 
and permit the dislocation. These operations differ for the various 
joints. General principles concern the technic of narrowing the cap- 
sular structures. Rows of stitches can be inserted in one axis and, 
when drawn taut and tied, cause a capsular shortening in the opposite 
axis. The capsule can be pinched up, sewed together, and the lax 
portion plicated over by retaining stitches or cut off entirely. Muscles 
can be shortened by exsection of parts of their tendons or by moving 
and reattaching their insertions. Fascial flaps may be swung over 
a loose and weak part of a joint from neighboring tissues, or a trans- 
plantation of fascia from the thigh may be put on as a patch. These 
operations are performed without opening of the joint, unless there is 
a loose fragment of bone or cartilage which must be removed. When 
all methods fail and the recurrence causes provoking disability, an 
arthrodesis can be done. 

Old unreduced dislocations cause much change about the joint, as 
has been described in their pathology. Treatment depends on the 
age and the evidence of bony and fibrous restriction about the dis- 
located bone ends. Many of them are accompanied by small frac- 
tures, as we have seen, and all are likely to have firm adhesions to the 
periosteum, and surrounding soft parts as well as bloodvessels and 
nerves. The muscular shortening and the filling in of normal joint 
cavities preclude reduction by manipulation and traction. Formerly 
strenuous efforts were made by forcible traction to pull these long 
displaced joints back into position. It is difficult to say just how 
much change has taken place around the joint in any given case, even 
by the aid of the roentgenogram, and each old dislocation should be 
subjected to mild manijmlaiive and traction efforts before open opera- 



182 DISLOCATIONS 

tioii is pcrt'oniKMl. Ex})cri(MK'c sliows, liowcv^er, that very few can be 
RMhiced hy the means of nianii)iihiti()n, and of those which are forcibly 
bronght back into position, a large proportion suffer injury to blood- 
vessels and nerves which is serious, or infection attacks the joint and 
causes the complication most feared of all. A certain small propor- 
tion escape these complications, but function is never satisfactory, 
and after the manipulative inflammatory reaction ankylosis frequently 
follows. A better functional position of a forearm and hand or any 
limb may be obtained often even though it is ankylosed. Although 
general indications may be laid dowai for operative attack of these 
old unreduced joints, each individual case must be judged on its own 
findings. It has been my experience that women make better patients 
than men for operative relief on joints. They have smaller bones 
and often more subcutaneous fat and are more persistent in efforts 
to obtain results for cosmetic reasons. A decision must often be made 
in certain joints, particularly the hip, between attempts to reduce 
the head into the acetabulum, excise it, or produce a bony ankylosis 
between the femoral neck and ilium. (See Fractures of the Neck of 
the Femur.) The problem of mobility versus strength must also be 
considered. Rigid strength is often of greater functional value in the 
hip or other joints than mobility, which would lead to pain and weak- 
ness after use. Pain from pressure on nerves or trophic disturbance 
resulting from the same cause is amenable to relief by operation. The 
danger of infection in the joints and the sloughing of tissue flaps must 
be weighed. Osteotomy below the trochanter of the femur or above 
the condyle of the humerus presents a chance for many functional 
improvements. 

Surgeons prefer to treat these cases by arthrotomy. Each, type of 
joint offers problems peculiar to its topography, and but few general 
remarks can be made covering the subject. The rules I follow are 
these: One incision only is used unless it is utterly impossible thus 
to make an exposure. Important nerve and vascular structures 
which cross the joint are identified and isolated if they lie within the 
operative field; otherwise they are retracted with the soft parts by 
being freed in a dissection which keeps close to the bone. Ligaments, 
scars, and callus which interfere with freedom of the bone ends are 
carefully cut away by sharp dissection and chisels. Attention is 
given to freeing the joint on all contacting surfaces and obtaining free- 
dom of motion in all normal directions. About some joints tendons 
must be cut. They can be united, or left free if divided near their 
insertion. If reduction cannot be made without great strain and 
pressure on the soft parts, it is wiser to resect part of the bone ends; 
07ie bone is usually selected, and the cut-off end is fashioned to corre- 
spond with the original joint. Very few joints can be thus reduced 
after extensive operation and freedom of motion be hoped for without 
the additional use of interposing flaps of fat, fascia, or muscle. Con- 
sequently the complete operation really consists in arthrotomy plus 
arthroplasty and in some cases excision of bone. 



AFTER-TREATMEXT AXD RESULTS OF DISLOCATIOXS 183 

After-treatment and Results. — Traumatic dislocation which is 
reduced soon after the hixation rec^uires rest for the heaHng of cap- 
suhir tears and absorption of intra- and periarticuhir effusions. Some 
dislocations are attended by great local infiltration. The greater the 
reaction, the longer the rest needed after reduction. Dislocations 
caused by direct violence which sustain great capsular damage as a 
rule demand a long period for regeneration of the lacerated tissues. 
When pain ceases in the joint and swelling subsides, active use can 
be started within the painless limit. Generally a simple sling or a 
light padded splint affords sufficient protection and immobilization 
for a week or ten days. It is best to avoid positions of the limb which 
will throw stress on the weakened and healing tear in the capsule. 
If joints are immobilized too long they become stiffened, and after 
dislocation the time for beginning movement must be selected in 
accordance with the joint involved and the amount of painful reac- 
tion. Light massage has an influence on the circulation in the peri- 
articular structures and muscles, and should be employed for that 
purpose alone, not as a forcer of passive motions. Function after 
uncomplicated reduced dislocation usually becomes normal again. 

Habitual and recurrent dislocations need a longer period of immob- 
ilization, generally in a permanent dressing for three or four weeks, 
with restriction of motion by a guarding splint or adhesive dressing 
for a period of one to six months thereafter. The after-treatment 
also depends on the character of the original method of treatment, 
whether operative or not. Failure to obtain permanent reduction 
frequently exists. (See the Specific Joints.) 

The after-treatment of old dislocations reduced by extensive opera- 
tion is a matter of considerable importance. If the joint is a super- 
ficial one like the elbow or knee, it is common to find sloughing of 
part of the skin which is under the greatest tension. This usually 
involves only the superficial surface, and every effort must be made 
to keep the gangrene dry. Stitches must not be removed from the 
skin early, even in the face of light infection. Alcohol dressings, care 
in handling, elevation, and anodynes for pain constitute the line of 
treatment. ^lost of all the surgeon and patient must not despair of 
a fair final result. If the edges of wounds slough, they must be kept 
clean and allowed to granulate, skin grafting following later. Passive 
movements must be persisted in from a time within a few days after 
operation, and active contraction of the muscles must be constantly 
encouraged. Final results take many months to culminate, and if 
failure results from the standpoint of mobility, the limb's contour and 
position are often greatly improved. When ankylosis threatens, the 
joint should be allowed to stifi'en in a position which will promise the 
best functional use of the limb. 



CHAPTER VIII. 
FRACTURES OF THE SKULL. 

The bone lesion in skull fractures is for the most part the least 
significant feature; the associated damage of the cranial contents 
is far more important. A split or depression of the skull in itself is 
of no great moment, and consequently the subject of fracture of the 
skull alone is a small one. The interrelation between the brain and 
its covering is so close, however, that we must study skull injuries 
largely from a physiological standpoint in regard to their disturbance 
of the central nervous system, and must understand the mechanism, 
signs, and symptoms of the bone injury in order to interpret the 
cerebral disturbances. 

The adult skull is a rigid mass of bone nearly globular in shape. 
The vault affords an almost uniform bony continuity with closed 
sutures, but the base is punctured by many openings for nerves and 
vessels. The base is also buttressed and supported by ridges of heavy 
osseous tissue, and when a dried skull is held before a strong light one 
has little difficulty in picking out the thinner and weaker areas. These 
are located in the three fossse, the anterior cerebral, the middle, and 
the cerebellar, which are the favorite site of cracks extending along 
the skull. Hilton has described also the strong points of the vault of 
the skull, which are furnished by buttresses. The principal one is an 
anteroposterior thickening of the bone extending from the glabella 
to the occipital protuberance, and there are besides two lateral ridges, 
one anterior, arising from the external angular process, passing upward 
through the frontal eminence to the anteroposterior buttress, and the 
other posterior, from the basilar processes through the parietal emi- 
nences to the midline above. 

Adult bones vary in size and amount of cortical tissue, and nowhere 
is this better illustrated than in the skull with its two layers of com- 
pact bone and the soft cancellous diploe, which carries bloodvessels, 
lying between. Cranial bones are very thin in some adults and the 
diploe, a very meager space between the tables, while the child's 
undeveloped bones are much softer and withstand bursting pressure 
better on account of their greater elasticity. Roentgenograms have 
added much to our knowledge of skull injuries, as they have to all 
bone lesions, and diagnosis can be made with greater certainty by 
their help, particularly in question of the presence and extent of 
fractures at the base. 

Accepting the bone lesion as a relatively secondary matter, we find 
a simple classification to consist in (1) I^idented or punctured frac- 
tures. (2) Bursting or radiating fractures. 



BURSTING OR RADIATING FRACTURES 185 

These two types may be combined, but they are in large measure 
distinctly separated and afford a convenient difference in mechanism 
and evidence of fracture. 

Skull fractures may also be classified as open or closed, or, in accord- 
ance with the lines of fractm-e, as comminuted, depressed, linear, 
fissured, or with loss of substance. Clinically they are also often 
divided as fractures of the base and vault. 

Indented or Punctured Fractures. — Indented or punctured frac- 
tures are caused by a body striking the skull with sufficient force to bend 
the bone toward the cranial cavity and expending its power quickly 
before the skull is altered in shape so as to cause lesions at a distant 
point. This situation may result in a fracture of either one or both 
tables of the vault and a carrying in toward, or into, the brain sub- 
stance, of fragments of bone. The outer table may be bent in or 
indented and slightly depressed into the diploe without injury of the 
inner table, or the elasticity of the outer table may save it from a 
loss of continuity while the inner table is broken and depressed into 
the cranial cavity. This localized indentation of the vault arises 
from the causative forces overcoming the local resistance or elasticity 
in a small area. This elasticity is resolved into two components, one 
a tension resistance against force tending to p\ill the bone parts asunder, 
the other a pressure resistance against compression. It has been shown 
that the resistance against pressure is about one-third greater than 
the tensile strength (Rauber) a fact which would explain the circum- 
stance that the outer table bends and may spring back into former 
shape unharmed, while the inner table gives way because of less tensile 
strength. It is exposed to force tending to pull apart its component 
particles, the same force driving together the particles of the outer 
table. Hence if the force has exhausted itself at the time the inner 
table breaks, the outer table remains unbroken, but if it acts beyond 
this point the outer table is also fractured. In this usual condition 
of fracture of both tables, the inner suffers damage over a wider area 
than the outer, and as the shock-absorbing diploe is necessary for 
this mechanism, we do not see this condition illustrated in the skulls 
of children and the old. With them the two tables are broken together 
and in about the same extent. Adults who are deficient in diploe, 
when subjected to fracture force sustain severe comminuted lesions. 
Gunshots which make a sudden sharp puncture and then proceed to 
penetrate the opposite side from within outward reverse the order of 
this mechanism (Fig. 36). 

These punctured injuries are caused by small blunt or sharp objects 
striking the skull, as a pointed stick, a gunshot, or an umbrella ferrule 
driven into the vault or base, or by falls on a -sharp edge of a stone 
which punches a hole in the bone. Small and sharp bodies puncture the 
bone, larger and blunter objects indent in a linear manner with an area 
of depression on one or both sides or drive in a large piece of the tables. 

Bursting or Radiating Fractures. — Bursting or radiating fractures 
are caused by a soHd hody striking the vault with force, or to indirect 



18(1 



FRACTURES OF THE SKULL 



violciKT from forcible jars of the s])inc transmitted via the condyles 
of the occiput. These forces do not indent the bone at the point 
of contact, but the lines of force break up and pass out around the 
<>;lobular skull in radiating directions, causing long cracks with varying 
degree of separation and most often seeking the weaker fossae men- 
tioned. Formerly it was considered that the skull broke at a point 
distant or opposite from the apphcation of trauma, on account of 
transmission of the force through the semielastic bone which resulted 
in a cojitrecoup. This theory has now been abandoned, and the irradia- 



1 











F[G. 36. — Illustration of a probable mechanism of skull fracture. First an inbending 
of both tables followed by fracture of the inner table alone or both tables. 



tion theory of Aran^ advanced in 1844 and since modified by knowl- 
edge of elasticity of the skull, has been accepted as the basic explana- 
tion of bursting. Force is applied diffusely and transmitted in merid- 
ional axes in direction of a pole opposite, forcing these two poles 
together and simultaneously altering the diameter of the plane per- 
pendicular to the compression polar diameter. If the limit of elasticity 
of the bone is not reached, no fracture will occur, as the bone springs 
back into shape. If this force acts very quickly before the skull can 
rebounfl, as described in the punctured fracture, there follows local 

1 Arch. gen. de Med., 4th Series, vol. iv. 



BURSTIXG OR RADIATIXG FRACTURES 187 

iiuleiitation of the hone. Should the tensile or eohesive strength 
of the bone he overeonie at a (Hstanee from the ai)pHeation of foree, 
the result is a bursting rupture along those axes parallel to the polar 
diameter wliieh have been compressed to the breaking point. Indirect 
violence transmitted from the spine results in a bursting fracture of 
an u'regular circular character at the skull base, and into the displaced 
area fissures or lines penetrate from the point of impact. 

It is further observed and substantiated by von Bruno and von 
Wahls's experiments that because the base is tlie weaker hemisphere 
of the globular skull it makes little difference in which direction the 
polar diameter of the force extends, because the portion of the meridian 
passing through the base will give way first. Consequently different 
types of causati\e trauma, a blow on one side of the head, a squeeze 
of the whole skull, or a diffuse blow on the vertex may cause the same 
basal fractures. ]Most of these bursting fissures, found at autopsy or 
in the roentgenogram, tend to run in a transverse diameter, but they 
occasionally pass in a longitudinal direction. Excellent illustration 
of this is given by Homans,^ who compares these skull fractures to the 
cracking of a pecan by force applied at each end. Radiating cracks 
appearing in the nutshell take a general direction from pole to pole 
in the long, meridian lines, but their exact course is determined by the 
weaker spots in the shell. Similarly in the skull, the cracks appear to 
take the direction of the causative force and pass toward the opposite 
pole, being influenced by the weaker spots of the thinner-walled fossae. 
Felizet, in 1873,'- reiterated this idea and asserted that the bursting 
fractures almost invariably ran out through these three fossae, and 
that external evidence of damage to them was easy to explain. Wal- 
ton^ took this idea up again, and it is at this time the most widely 
accepted physical theory of these injuries. 

Frequency. — Out of a total number of 11,302 fractures reviewed by 
the author, there were 1136 skull fractures. For the sake of sim- 
plicity, an average year (1914) may be taken. In this year there were 
148 cases admitted to the Cook County Hospital, of which 71 died, 
73 recovered to return to a more or less normal condition, and 4 
were badly demented or suffered mental changes permanently as far 
as the records show. Many patients left the hospital within a week 
after injury, and no further information about them can be obtained. 
Analysis of the 148 cases of a typical year shows that 118 were basal 
fractures and 30 were strictly of the vault, 9 being specified as linear, 
and 9 as having depressed fragments of bone. Of the total number 
of 1130 skull fractures the mortality was nearly 50 per cent. In the 
time covered by this number, 8 years, there were performed 12() opera- 
tions for elevation of fragments or for other decompression procedures, 
followed by death in 63 cases, exactly 50 per cent. Although the 
technic and possibly the selection of time and indications for oj^era- 
tion have improved in these 8 years, it may be interesting to show 

' Boston Med. and Sure. Jour., dxvii, No. 20, p. 6K5. 

2 Th6sc de Paris. ^ Ann. of Sum., Novembor. 1904. 



188 



FRACTURES OF THE SKULL 



that the postoperative mortaUty has varied Httle and at least has not 
lessened. 



1907 number operations on skull fractures 21, deaths 9 

1908 
1909 
1910 
1911 
1912 
1913 
1914 



23 " 


13 


11 


2 


11 


6 


17 


11 


16 " 


7 


14 


7 


13 " 


8 



Pathology. — 1. Punctured Fractures.- — Small indentations of the 
tables of the skull, either one or both, may result in no damage to the 
brain beneath. If both tables are depressed by a blunt object, the 
dura may remain intact, and there will be little pressure on the brain 




Fig. 37. — Punctured fracture of the frontal region. The outer table has been depressed. 
The inner table has also been depressed slightly and is extensively comminuted. 

(Figs. 37 and 38). Hemorrhage may occur from the superficial tis- 
sues, which are usually lacerated, or from the diploe, and if vessels 
of the dura are opened they may also contribute to a bloody discharge. 
Usually the inner table is more comminuted and exhibits a larger 
fractured area than the outer table. The inner table alone may be 
fractured and depressed without apparent damage of the outer table, 
but these cases are very rare. Concussion of the brain and death are 
not frequent in this type without other injuries. Gunshot and umbrella 
punctures usually penetrate the brain substance and have complica- 
tion from immediate injury to the central nervous system, or from 
later consequences such as hemorrhage, meningitis, and abscess. This 
is especially true when the accessory sinuses of the face or the eye 
and nose are opened into. Ross^ reported a case of punctured wound 



" Ann. of Surg., xlvii, 108. 



BURSTING OR RADIATING FRACTURES 



189 



in the right orbit which resulted in a cerebral abscess involving the 
whole right temporosphenoidal lobe. The greater wing of the sphenoid 




Fig. 38. — Operative repair of the precedinfr. Bone fragment of the outer table 
removed. The depressed comminuted inner table elevated a normal level. Dura not 
injured. Recovery. 

was found fractured, and the floor of the orbit was opened into the 
roof of the antrum of Highmore, showing the line of the infection from 
the nose via the antrum to the middle cerebral fossa. The punctured 




Fig. 39. — Open fracture of skull from bullet wound. 



fractures due to high-velocity bullets are fatal for the most part either 
on account of immediate brain injury, or later infection and hemor- 



190 FRACTURES OF THE SKULL 

rhage. Wharton^ collected a series of 316 cases of foreign bodies in the 
brain. Some of these were caused by swords and bayonets, others by 
ferrules of canes and umbrellas; five were penetrations of the sphenoid, 
and 18 were wounds of the orbit.^ 

Friedrich"^ kept full record on 43 cases of firearm wounds of the 
skull and brain and had very high percentage of recoveries. He did 
not trephine in all cases unless there was evidence of cerebral symp- 
toms. The author has seen 2 cases of suicidal gunshot punctures 
which severed both of the nerves and caused complete blindness, 
but no other symptoms. Gunshots of the skull and brain studied 
from their physiological standpoint have confirmed many of the 
brain localizations worked out by experimental physiology. Roth- 
mann"^ has reported some interesting cases regarding the visual centres 
in the occipital lobe and various motor aphasias which were cured 
by removal of the bullets from areas physiologically anticipated. 

Horsley, in 1894, experimented on the explosive effect of high- velocity 
bullets in connection with gunshot wounds of the head.^ He used 
modelling clay which contained some water, and after the explosive 
force had deformed the mass he filled the cavities with plaster of Paris 
to preserve the effect of the shot. The conclusions reached were that 
the explosive effect of the bullet was directly proportional to the 
sectional area of the bullet, its velocity, and the amount of water in 
the substance through which it passed, the forces of disruption acting 
at a right angle to the axis of the bullet's flight. The greatest amount 
of damage was done by the bullet when at its highest velocity and 
surrounded by the largest mass of wet tissue. 

In animals and in the skull of man these conditions are influenced 
by the fact that the water-holding material, i. e., brain, is surrounded 
by a semielastic bone envelope. The larger wound of exit of gunshots 
in the human body is caused by the driving out, in penetration shots, 
of all fragments of bone or other tissues to which the velocity of the 
bullet has been communicated. 

Modern bullets possess two movements, the forces of which have 
a bearing on the injury. These are the forward progressive penetra- 
tion and the rotary spin arising from the rifling of the gun barrel. Of 
these two the most important is the rotation of the bullet, the effect 
of which Horseley observed was still visible on the plaster casts of his 
experiments up to the time when the bullet ceased to penetrate. He 
believes that the disruption of tissues in wet clay must be attributed 

1 Philadelphia Med. Times, July 19, 1913. 

2 Cases of punctured fractures not followed by abscess or infection: Brown and Birch, 
Philadelphia County Med. Soc, 1889, x, 395; Ferguson, New York Med. Jour., 1896, 
Ixiv, 300; Semonnier, Bull. Soc. Med. et Chir. de la Drone, 1904; Fisher, Deut. Ztschr. 
f. Chir., 1882 3, xviii, 411; Kennedy, Glasgow Med. Jour., 1905, Ixiii, 394. Cases followed 
by abscess: P^elty, Med. News, Philadelphia, 1894, Ixv, 710; Rehns, Aerztl. Int. Blatt., 
Munich, 1881, xxviii, 45; Pridean, Lancet, London, 1886, ii, 846. 

3 Beitr. z. klin. Chir. Tubingen, xci, No. 2. 
^ Berl. klin. Wchnschr., lii. No. 13. 

5 Proc. Roy. Instit. Great Britain, 189.5, xiv, 228; British Med. Jour., February 20, 
1915, No. 2825. 



BURSTING OR RADIATING FRACTURES 191 

for the most part to the water, because particles are thrown off at 
right angles to the axis of the bullet's flight. In a number of the 
Lancet (London) for 1915, two cases of gunshots of the head reported 
by a correspondent confirm these ideas. In one case a shot of maxi- 
mum velocity entered the head just in front of the ear, and made 
exit at a point exactly opposite. The bullet track was straight, and 
although the wound was really a wound of the face, it proved instantly 
fatal. When the skull was opened, it was found that death was prob- 
ably caused by the condition of the under surfaces of the frontal lobes 
of the brain, which had been reduced to a structureless jelly by the 
lines of force emanating from the rapidly traveling bullet. A second 
case had occurred after the bullet had travelled 2000 yards and had 
a small residual momentum. This bullet had entered the forehead, 
traversed the head, struck the occipital bone on the inside, and 
rebounded over the original track to a place near the point of entrance. 
There was no general bruising of the tissues about the track of the 
bullet. 

The sectional area and not the shape of the point of the bullet is 
also of importance to the character of the result of the shot. Soft- 
nosed or dumdum bullets deform easily, and their expansion increases 
their sectional area greatly, but modern hard-nosed bullets make the 
same wound whether of blunt or long nose. Horsley also showed that 
turning over of the bullet was common, but that the bullet turned 
only 07ice, near the middle of its course through the clay, at a point 
when its progression velocity was greatly reduced and the advance 
of the bullet became more sensitive to obstructions. The first effect 
of these obstructions is felt by the lighter tip of the bullet. The bullet's 
heavier base swings around, converting the primary tubular wound 
into a triangular cleft, the base being formed by the broad base of the 
bullet and the apex by the point. The turning over does not produce 
as much harm as the high velocity and the continuance of the rotary 
spin. 

Punctured fractures may result in the formation of meningocele 
from hemorrhage, or this may result from irritative secretion following 
trauma. Hayner^ cited a case of ten years' standing in which a large 
cyst, which gave but few eye and headache symptoms, compressed 
the occipital lobe. Its outer wall was formed by the pericranium. 

2. Bursting Fractvres. — These frequently have no scalp lacerations 
but may show a swelling or ecchymotic area on the head. Lines of 
radiating fracture pass across the vault, usually toward a point oppo- 
site the application of the trauma; or radiate down into the fossae at 
the })ase, across the middle line, and sometimes into the foramen 
magnum, the orbits, or through the ])etrous portion of the temporal 
bone into the middle ear, rupturing the tympanic mem})rane. The 
cracks in the bones are of little interest in themselves, but are very 
important in their relation to the division of meningeal vessels which 

' Ann. of Surg., liii, 209. 



192 



FRACTURES OF THE SKULL 



are partly imbedded in the bone and the hemorrhage from which may 
be inaccessible. The brain may be jarred and concussion follow; blows 




Fig. 40. — Vertical linear fracture without a scalp wound. As far as the roentgenogram 
shows this does not extend into the base. 




Fig. 41. — Oblique linear fracture in the temporal region. This is the type which involves 

the meningeal artery. 



severe enough to cause concussion do not always break the skull. 
The brain in fracture may be shaken and lacerated for a distance of 



BURSTIXG OR RADIATING FRACTURES 



193 



several centimeters into its substance, and cortical hemorrhage may 
occur, especially hemorrhage into the pia mater, which gives a bloody 




Fig. 42. — Linear fracture originating in the frontal region and passing backward in the 
longitudinal axis of the skull. 




Fic. 43. — Bursting fracture in a child's skull passing clear around the vault and giving 
symptoms of basal involvement. 

cerebrospinal fluid. On account of the rapid circulation of this fluid 
and its absorption by the arachnoidal villi into the venous sinuses,^ 



Weed, Jour. Med. Research, 1914, xxxi, 51. 



13 



194 



FRACTURES OF THE SKULL 







Fig. 44. — V-shaped fissure, one leg running into the mastoid and middle fossa. Hemor- 
rhage from ear. 




Fig. 45. — Irregular fissure involving orbit with hemorrhage. 



BURSTING OR RADIATING FRACTURES 



195 



the finding of bloody cerebrospinal fluid by lumbar puncture gives 
immediate evidence of cortical hemorrhage. Cerebral edema causing 




Fig. 4G. — Fissure in long axis of the skull involving the occipital bone and lobe of the 

brain. 




Fig. 47. — A more extensive separation involving the occipital region. No scalp 
wound. Hemorrhage from ear. There is some depression of the outer table at the site 
of fracture. 



increased intracranial pressure ma\ follow within a few hours, or after 
several days. 



190 FRACTURES OF THE SKULL 

The brain is also subject to a compression from meningeal or dural 
hemorrhage as a direct result of the bending skull fracture. Because 
many of these fractures pass through the temporal fossa, the vessels 
which groove the bone are likely to be torn, and hemorrhage from them 
occurs outside the dura, the force of arterial pressure dissecting the 
meninges away from the inside of the skull and causing a hematoma 
formation. (See Symptoms of Middle Meningeal Hemorrhage.) With 
increasing cerebral pressure symptoms and a normal cerebrospinal 
fluid, extradural hemorrhage is suspected, although both intra- and 
extradural forms may be present simultaneously. 

Hemorrhage from the ear, nose, pharynx and into the orbits, pointing 
beneath conjunctivae and lids, or ecchymoses and edema about the mas- 
toid, are found, depending on whether the cracks are in the temporal 
bone, the middle or anterior fossse, the orbital wall, or the inferior occip- 
ital fossae. Deafness may follow bursting fracture; the author has seen 
one case Liiken^ reports an instance in a man who fell twenty feet 
and landed on his head, the mechanism probably being pressure of the 
axis transmitting the body weight against the occipital bone causing 
a bursting fracture at the base of the cranium forward through the 
jugular and carotid foramen into the sella turcica. The glossopharyn- 
geal, vagus, and accessory spinal nerves lying in the jugular foramen 
were exposed to injury — the accessorius and vagus were damaged with 
the resulting deafness. Deafness might also follow hemorrhage into 
the inner ear and semicircular canals, but this is accompanied by ver- 
tigo and other pronounced symptoms and is rare. Blindness without 
visible injury of the eye-grounds has also been noted. Newmark^ 
reports three cases following the trauma of bursting fracture. The 
partial loss of vision was not recognized by the patients and was 
caused in part by bilateral occipital hemorrhage or injury to the 
occipital lobes. The vision was greatly circumscribed and central. 
One case of a four-year-old boy gave a long, slow recovery. Severe 
diabetes after skull fracture with death in ten months was reported 
by V. Noorden.^ Churchman^ has recorded a case of basal skull frac- 
ture with motor aphasia and recovery after operation. He found a 
superficial laceration of the paracentral gyrus of the left frontal lobe 
in the Broca area. The patient made a complete recovery from his 
aphasia but became slow mentally. In May, 1915, I had two cases 
of aphasia following skull fracture in young boys. The first case was 
in a lad of fourteen years, who was injured by an automobile. He had 
an open fracture of the left parietal region and undoubtedly had exten- 
sion cracks involving the basal fossae. He was not unconscious and 
had no focal symptoms nor paralysis. There was some twitching of 
the right side of the face, but no eye symptoms. His only trouble 
seemed to be an inability to talk. He could read printed words, could 

» Arch. f. klin. Chir., civ, No. 4, p. 1000. 
2 .Jour. Ophth. and Oto-Laryngol., viii, No. ,5, p. 143. 
•'' Jour. Am. Med. Assn., October 16, 1909, liii, 1303. 
4 Ibid., Ixiv, No. 15, p. 1233. 



BURSTING OR RADIATING FRACTURES 197 

understand everything said to him, and answered by head move- 
ments. His tongue showed no paralysis. Decompression was per- 
formed, and a depressed area of bone just posterior to the Rolandic 
fissure was elevated. The dura was opened and the cortical surface 
was explored well forward into the supposed speech-centre area. 
Some cortical edema was present but no surface laceration. A large 
fissure extended backward toward the occipital bone, from which 
direction subdural hemorrhage arose. A good-sized area of bone was 
removed, and gutta-percha drainage was inserted. Convalescence 
was satisfactory. The scalp healed promptly after several days' dis- 
charge of cerebrospinal fluid and blood. After four or five days his 
power of speech gradually returned, and within two weeks he could 
talk normally. There was no disturbance of gait or equilib- 
rium. 

The second case was at Provident Hospital in a seven-year-old boy 
who had been struck on the left parietal and frontal bones by a base- 
ball bat. This was also an open fracture with depression in the tem- 
poral fossa of a circular fragment about the size of a silver dollar. 
The lad was conscious and had no focal symptoms except slight facial 
paralysis of the right side. He was unable to talk, but understood 
questions and could put out his tongue. The fragment was raised and 
the dura was found to be lacerated, as was also the cortical surface 
in the neighborhood of the paracentral gyrus. Four days after the 
operation he began to talk and went on to a perfect recovery, going 
home on the twelfth day. Whether these aphasias arise from con- 
cussion injury of the supposed speech centre in the frontal lobe or 
from injury of the occipital lobe is not posit ivel}' known. The con- 
clusion of much experimental and clinical observation favors the theory 
of injury to the occipital lobes, and the identity of a definite speech 
centre is questioned. Other pathological changes involve degeneration 
of the cranial nerves, especially the optic, acute and subacute paren- 
chymatous inflammation of the cerebral cortex which may terminate 
in abscess or sclerosis. Secondary and delayed pathological changes 
include cerebral softening, sclerosis, and abscess. 

S3nnptoms. — (1) Punctured Fracture. — The symptoms, as indicated 
in the pathology, group themselves around the bone injury and the 
brain damage. A punctured wound of the skull will nearly always 
be accompanied by an external wound of the scalp or head tissues 
from which there is hemorrhage, discharge of cerebrospinal fluid, or 
protrusion of brain substance. Injury to the vault with a scalp wound 
means an open fracture. Through the scalp opening the hole or 
depression of the skull tables can be seen or felt and the existence of 
fracture verified. Punctures of the base or through the face are more 
fiifficult to determine, and measurements of the wound depth with 
a probe, or roentgenograms of the head with a probe lying in the 
wound, will be of invaluable aid. Bullets and foreign bodies can be 
located accurately by stereoscopic pictures. The escape of cerebro- 



108 FRACTURES OF THE SKULL 

spinal fluid or pieces of brain tissue is also proof of penetration into 
the brain. Delayed symptoms are a sudden or gradual rise in tem- 
j)erature a few days after injury when the j^revious course has been 
afebrile, or a normal pulse rate which falls to 50 or lower, both indi- 
cating infection and abscess. Likewise disturbances in consciousness, 
irritability, or increasing somnolence are signs of infection, while 
headache alone is not sufficient. Friedrich advises the importance 
of taking the patient's temperature between midnight and 2 a.m. 
to obtain the earliest evidence of a rise in a case which is afebrile at 
all other hours of the day. 

The venous sinuses may be opened directly by a punctured wound 
and give a copious hemorrhage of venous blood which is difficult to 
control. Cerebral concussion and other brain symptoms which 
depend on the disturbance of the central nervous system will be 
described under Bursting Fracture. 

2. Bursting Fracture. — This may accompany or be an extension of 
punctured fractures. Bursting linear cracks may be limited to the 
vault or pass into the base as described, and symptoms may be absent, 
the roentgenogram confirming the presence of the cracks. A scalp 
wound or a hematoma beneath the scalp is not necessary, and in 
many bursting fractures which involve the base these are absent. 
Concussion of the brain or loss of consciousness generally accompanies 
these head injuries, although this happens without bone injury. It 
is the easiest sign to recognize, and changes in consciousness without 
complete loss, are important. The patient may be unusually quick 
and bright mentally and answer all questions freely and correctly, 
and in a few hours not know that he has ever seen the surgeon nor 
made replies. 

Damage to the medulla is a more acute type of this concussion, and 
the vital function most easily influenced is respiration, with vagus 
control of the heart and interference with the vasomotor centres and 
a lowering of blood-pressure following in order. According to the 
severity of the concussion, we may find first a change or loss of con- 
sciousness, usually transient and unaccompanied by other signs. 
Secondly, we find a loss of consciousness with respiratory changes, 
usually a rapidity or Cheyne-Stokes type, and a rise in blood-pressure 
and a slow, full pulse, which endeavors to compensate and carry blood 
to the medulla. A more severe stage is characterized by loss of con- 
sciousness, a rapid, weak pulse, and irregular respiration, which, if 
not followed by a compensatory rise in blood-pressure, leads to early 
death. 

When the jarring is greater, the brain may be shaken and badly 
bruised with a laceration of its substance, without demonstrable 
fracture. These injuries result in hemorrhage which is shown by lum- 
bar puncture. If the spinal fluid is blood-tinged and under pressure, 
so that it runs out of the needle at a rate faster than the normal 
dropping, increased pressure and hemorrhage from cerebral laceration 



BVRSTIXG OR RADIATING FRACTURES 199 

are positi\e. This is an immediate sign of great vakie. \>ry rarely 
differentiation from intraventricular hemorrhage has to be made. 

LeConte and Bissell/ in 200 autopsies on deaths in coma at the 
Cook County Hospital, found that the a\'erage age of cases dying 
from cerebral hemorrhage was over fifty, while the average age of 
fatal cases of skull fracture was at least ten years less. It is also 
interesting to note in studying the clinical histories of these cases 
that the skull fractures gave great variation in the blood-pressure, a 
relatively low average being found, whereas the cerebral hemorrhage 
cases were uniformly high and averaged nearly 190. The most impor- 
tant and the earliest sign which can be obtained, and that while the 
patient is unconscious, is the presence of blood in the spinal fluid. In 
old cases, with healing or healed scalp wound and unconsciousness or 
sudden rises in temperature, the finding of pus or a spinal fluid with 
great excess of leukocytes is also uniform. Spinal puncture in head 
injuries and comas should become a routine method of examination. 

^Meningeal hemorrhage occurs most often when the vessels grooving 
the bone are ruptured. Usually this occurs in cracks across the tem- 
poral fossa and the middle meningeal is the vessel involved. A primary 
unconsciousness due to the concussion is followed by a period of con- 
sciousness of varying length, succeeded by another lapse into uncon- 
sciousness with evidence of increasing intracranial pressure. The 
secondary unconsciousness is caused by the gradual development of 
the extradural blood mass, which exerts enough pressure to encroach 
on the motor centres, or inhibit sufficient blood supply to the brain, 
a cerebral anemia following. If other less important meningeal ves- 
sels are torn, hemorrhage is slower, and the symptoms are those of 
gradually failing consciousness and paralysis of slow onset appearing 
late after the brain is recovering from other injury. The extradural 
hemorrhage alone does not give a bloody spinal fluid as mentioned 
in the pathology. If the symptoms of the first shock do not improve 
inside of a few hours, if the depression of the medullary centres 
evidenced by rapid pulse and respiration is not overcome, or if uncon- 
sciousness deepens even without definite focal symptoms or evi- 
dence of bone damage, the injury is undoubtedly to be classed as 
severe. When the patient is to survive, there is a reaction, and a 
compensatory slow pulse and high blood-pressure develop; but the 
injury may be so severe that this never occurs. 

A low degree of fever in the first few hours is common, and a rapidly 
rising temperature reaching from 105° to 108° is indicative of derange- 
ment of the medullary centre, and approaching death. The leukocyte 
count generally does not vary in the first twelve hours; after that it 
rises as high as fifteen to twenty thousand from effect of hemorrhage. 
Alcoholics do not react normally; they usually remain unconscious 
with a low blood-pressure and weak cardiac action. 

Hemorrhage is the one sure indication of bursting fracture involving 

' Jour. Am. Med. .\s.sn., xiv. No. .3, p. 180. 



200 



FRACTURES OF THE SKULL 




Fio. 48. — Irreguhir planes of bursting fracture passing from the vertex to both the orbit 
and the ear, producing subconjunctival and ear hemorrhage. 




Fig. 49. — A severe crushing of the skull with multiple planes of fractures and displace- 
ment of both tables. Recovery. This case practically is a decompression within itself. 



BURSTING OR RADIATING FRACTURES 



201 



the base. From the sources in the fossae described, it becomes visible 
upon or beneath the outside surface of the head. It may be manifested 




Fig. 50. — Child's skull fractured by fall from a height. There is wide separation of 

fragments. 




Fig. .51. — Severe bursting fracture vnth comminution. 

beneath the conjunctivse, from the nose, ears, mouth, or into the 
subcutaneous ti.ssues around the eyes or the mastoid regions. Phelps^ 



Ann. of Sur^., xlix, 449. 



202 



FRACTURES OF THE SKULL 



analyzed 1000 cases of head injury and obtained the following statistics 
of hemorrhage in 405 basal fractures : 



Hemorrhage from car 

Hemorrhage from nose and mouth . 
Subconjunctival hemorrhage 

{Mastoid 
Cervical 
Orbital 



Recovered. Died. 



166 
39 
9 
3 





L19 
51 

8 

61 

3 

1 



Total. Necropsies. 



285 
90 
17 

13 



69 
32 

7 



Ransohoff found hemorrhage from cranial openings beneath the 
conjunctiva and under the scalp in 163 out of 190 cases, hemorrhage 
from one ear in 60 cases, and from both ears in 8 cases. 




Fig. 52. — Recent bursting fracture with punctures. Note the hemorrhage from the 
left ear proving the presence of a crack in the middle fossa. A fatal termination. 



The author's observation of cases shows a larger percentage of sub- 
cutaneous hemorrhage about the orbit and a smaller proportion of 
ear hemorrhage. Immediate subconjunctival or orbital hemorrhage 
is caused by contusion at the time of injury; that caused by fracture 
involving the orbital wall does not show for several hours and is often 
delayed for one or two days. It passes through the colors and stages 
of absorption and in ten or twelve days has largely disappeared, the 
subconjunctival persisting much longer. Mouth and nose hemorrhage 
with no local lesion on the face, particularly nasal hemorrhage after 
twenty-four hours, indicates fracture through the anterior or middle 
fossa. These give a higher mortality than ear hemorrhage, probably 



BURSTING OR RADIATIXG FRACTURES 203 

on account of greater trauma and liability to infection from the septic 
nares. A hematemesis after head injuries, if tongue and other local 
injuries are absent, suggests fracture into the i)harynx or nose. Sub- 
cutaneous hemorrhage around the mastoid is caused by a splitting 
of the inferior occipital fossa, although a temporal hematoma might 
gravitate there. Edema from disturbed return circulation may also 
be a sign about the mastoid. 

Hemorrhage from the ear caused by rupture of the drum, following 
a bursting crack, is common, and the auditory canals should be care- 
fully inspected for its presence. When this symptom is present in 
closed bursting fracture, lumbar puncture should be made to determine 
the presence or absence of cortical and pial hemorrhage. 

Other s}Tnptoms of basal fracture are rare. Serous discharges from 
extravasated blood within the skull, cerebrospinal fluid, the discharge 
of middle-ear inflammation or a serous arachnitis, may come from the 
scalp, ear, or nose. Phelps found this in 26 cases, 9 of which were 
fatal, 7 from the ear and 1 each from the vault and nose. The 
cranial nerves may be involved either by pressure or injury in the 
peripheral portions or origins. Particularly the optic nerve is subject 
to an edema developing after a few hours of increased brain pressure, 
giving a choked disk on ophthalmoscopic examination, or the third, 
fourth and sixth nerves may be implicated. Vaughan, night warden 
at the Cook County Hospital, investigated the ophthalmoscopic 
findings of head injuries for a period of two years. In that time he 
found but 2 cases which showed even early symptoms of choked 
disk, and they were not cases of immediate injury. He is of the 
opinion that small retinal hemorrhages are seen early and are evidence 
of cranial damage. Strabismus, irregular and unequal pupils, failure 
to react to light, may be found. Unilateral dilatation is the common 
finding, Ransohoff found it 45 times in 127 cases, 11 of which died. 
The facial may also be involved so that a hemiparesis of the face 
muscles is present with a twisting of the mouth toward the unparalyzed 
side from unbalanced muscular action, and a blowing out of the 
paralyzed cheek in respiration. Irritative twitchings of the face are 
also commonly present. Injuries of other nerves governing the tongue 
action and swallowing may be present. 

Extrusion of brain substance is sometimes found in a scalp wound 
or into the nose and pharynx. Brewer^ reported a bursting fracture 
in a nine-months-old girl. Where the scalp was opened a three-inch 
fissure across the parietal bone was found, joined by another anteriorly. 
The skull was depressed at this line of fracture, and there was a 
sausage-shaped mass of necrotic dura and cortex two and a half inches 
long, by three-quarters of an inch in diameter, which had probably 
been pinched out between the bone edges as the crack opened. Paraly- 
sis and convulsions are primary or secondary, caused })y trauma or 
hemorrhage and increased intracranial pressure. Late convulsions, 

* Ann. of Surg., xlviii, 12.5. 



204 FRACTURES OF THE SKULL 

general and not epileptic in character, but due to delayed or recurring 
hemorrhage, may appear. Spiller^ reports an instance in a man of 
fifty-nine, who was unconscious for fifteen minutes following a skull 
injury, but who gave no evidence of paralysis or hemorrhage. He 
died of a bulbar paralysis after seven weeks, and the presence of 
hemorrhage in the bulb was verified by autopsy. 

Loss or change in muscular tone is present in some cases and is 
a valuable aid in diagnosis when complete unconsciousness exists. 
If a limb on one side is flaccid when raised and dropped, while one on 
the other has some muscle tone, the presence of cerebral mischief on 
the side governing the toneless muscles is indicated. Relaxed sphinc- 
ters with involuntary actions of the bladder and rectum are found in 
instances of severe concussion. These symptoms disappear as con- 
sciousness returns or persist if death is imminent. 

The findings obtained through ascertaining of the blood-pressure 
are very helpful in determination of prognosis and treatment. An 
average blood-pressure for the patient must be kept in mind, taking 
age, condition of kidneys, and evidence of arteriosclerosis into con- 
sideration. A fast pulse and respiration with a low blood-pressure 
are unfavorable signs; the high pressure and slow pulse with a gradual 
rise when recorded every few hours, are first-hand indication of the 
fight the individual is putting up to supply blood to his brain, and 
call for external help if accompanied by bloody spinal fluid, focal 
symptoms of pressure, or continued unconsciousness. The use of the 
blood-pressure apparatus should be as frequent and as carefully 
recorded as the thermometer findings. 

The use of the roentgenogram must also be recalled in the diagnos- 
ing of basal cracks and in the differentiation of comas. When the 
patient's condition permits, his head should be subjected to Roentgen- 
picture taking. This procedure helps rule out cases of concussion 
and also confirms bursting fractures through the base. Luckett and 
Stewart^ advise the exposure of the head to the rays with a minimum 
amount of disturbance and movement, although the head should 
be fixed absolutely and the respiratory movements must not disturb 
it. A hypodermic injection of morphine may be needed for this pur- 
pose. For obtaining a view of the frontal bone the patient may be 
turned on his abdomen, or the tube may be placed beneath the head. 
If the occiput is to be shown the chin must be sharply flexed. The 
grooves for bloodvessels on the inner table are sometimes mistaken 
for cracks of fracture. The fracture lines are light and sharp cut and 
have a varying width. 

Progress and Prognosis. — 1. Puncture fractures with little or no 
depression of bone and no concussion usually promptly return to 
normal unless infection occurs in the scalp and bone. This infection 
may lead to late meningitis or to cerebral abscess by extension. If 
concussion has been present, recovery from it is generally followed 

1 Univ. Penn. Bull., xvi, 13. 2 Am. Jour, of Surg,, xxviii, No. 1, p. 40. 



BURSTIXG OR RADIATING FRACTURES 



205 



by an uninterrupted convalescence, with rare secondary complication 
mentioned under Pathology. If puncture is uncomplicated, if frag- 
ments demand elevation and other operative procedures, the prog- 
nosis is good if there is no foreign body buried within the brain and 
no infection develops, 

2. Bursting fractures, especially those of the base, yield an average 
mortality of 50 per cent. The prognosis is largely indicated by the 
depth of the mental disturbance and the length of the unconsciousness. 
This is so well recognized that of the 1138 cases reviewed in this 
series only 126 were operated on, because the symptoms of severe 
brain injury and the futility of adding operative shock were appre- 
ciated. The value of immediate decompression in the cases struggling 
to establish a compensatory equilibrium within the brain was not 
appreciated. A large percentage die within the first twenty-four 




Fig. 53. — A peculiar type of bursting fracture known as the trident fracture. Note the 
3-prong or tooth-like projections of the plane of fracture. 

hours. Ransohoff^ reviewed the prognosis based on 190 cases in ten 
years' experience and found a general mortality of 63 per cent., only 
15 per cent, dying after the second day. The deeper the coma and 
unconsciousness, the poorer the prognosis; the more stertorous the 
breathing, the greater the indication of deep cerebral concussion and 
hemorrhage. Patients with coma lasting several days have recovered. 
Ransohoff cites one lasting six days. Coma developing late has an 
important bearing on prognosis, inasmuch as it indicates beginning 
infection, cerebral edema, or recurrent hemorrhage, and lessens the 
chance of recovery. 

Crandon and Wilson ,2 in the records of the Boston City Hospital 
collected 530 cases with a mortality of 44 per cent. Fiftj-nine were 



Ann. of Surg., H, 796. 



2 Ibid., xliv, 823. 



206 FRACTURES OF THE SKULL 

operated upon with a mortality of 53 per cent. Kantorowicz,^ utilizing 
the Charite records from 1902-7, found 73 cases of basilar fracture 
with 25 deaths. 

Other authors, as Schwarz,^ reports 38 cases from Kiel with 14 
deaths: Wanker,^ 66 cases with a mortality of 28 per cent., and Frazier^ 
found a mortality of 59 per cent, at the Philadelphia Episcopal 
Hospital. 

The question of the development of epilepsy following skull fracture 
and brain injury is a large one and need not be entered into in detail 
here. Elsberg^ makes the statement that one-third of all skull frac- 
tures develop general epilepsy or the Jacksonian type at any period 
from one to many years after the injury, and that unoperated cases 
are not more liable to have this sequence than cases operated on. 
The question of undisputed diagnosis of traumatic epilepsy will help 
determine this matter, and no figures will be authoritative until a 
large number of head injuries which are checked by roentgenogram 
can be traced for years from the standpoint of subsequent epileptic 
seizures. We do know at this time that but few cases obtain per- 
manent relief from operation whether adhesions to the dura and cortex 
are found and divided, or an area of the cortex is sliced off, or whether 
fat and fascia flaps cover the supposedly irritated area and bone is 
replaced as bone hash or an osteoplastic flap, or the space left devoid 
of that covering. It is also right to affirm that when depressed bone 
fragments and clots are left epilepsy can be expected. 

Treatment. — Treatment of skull fractures divides itself sharply 
along the line of the pathology, and it is not infrequently true that 
with a relatively mild bone injury, the damage to the brain and vital 
centres is so great that death is certain. 

General care and treatment for head injuries consists in preserving 
the patient from further shock which may result from rough handling, 
exposure or hemorrhage. If unconsciousness is of moderate type and 
the concussion of the brain is the most important feature, with symp- 
toms of rapid, feeble pulse, low blood -pressure and loss of vascular 
tone, vomiting, shallow respiration, and subnormal temperature, the 
indication is to apply external heat, diffusible stimulants such as 
strychnine or enemata, and give perfect quiet and rest. If transporta- 
tion to a hospital or some distant point is necessary, a hypodermic 
injection of morphine is indicated. The concussion must be over- 
come, as it may mask other and more serious symptoms which cannot 
be ascertained in its presence. It is also advisable to obtain as clear 
an account of the accident as can be given by witnesses, and careful 
notation should be made of -the condition of the pupils and the eye- 
grounds if possible, the presence or absence of hemorrhage from the 

1 Thesis zur Prognose d. Schadel Basis Briiche, Leipzig, 1908. 

- Schiidel Basis Briiche, Diss., Leipzig, 1903. 

3 Disser. Goettingen, 1900. 

" Jour. Am. Med. Assn., 1909, Hi, 885. 

Am, .Jour, of Surg., xxviii, 38. 



BURSTIXG OR RADIATING FRACTURES 207 

ears, eyes, nose, throat, lacerations of the tongue, and vomited blood. 
The scalp should be carefully inspected for contusions or the slightest 
clue of the point of injury in case there is no scalp wound, as a 
small finding may be of great assistance in determining subsequent 
treatment. 

Concussion and scalp wounds indicate close scrutiny. Because 
the scalp and pericranium are closely joined together, and no prolon- 
gation of the fibrous tissues are sent into the bones of the vault, the 
scalp may be widely torn or avulsed without skull injury. On the 
other hand, a small scalp wound which shows in its depth nothing in 
the nature of bone damage may conceal a depression nearby, or burst- 
ing cracks taking origin just outside of its range. False security and 
diagnosis will follow superficial examination of such a scalp injury, 
and it is good surgery to investigate each wound, enlarging it at the 
ends and cutting down to the bone if there is the slightest suspicion 
of fracture. 

Bursting fractures with evidence of hemorrhage at the base and 
with or without concussion or scalp wound are treated in accordance 
with the general principles. If the ears are bleeding, the canal is 
wiped out with a bichloride sponge and very lightly covered with a 
similar dressing. It is impossible to sterilize the nares in any degree. 
If the eyes later become swollen and edematous and some conjunctival 
discharge develops, mild antiseptic irrigation and sterile vaseline on 
the lids should be used. The patient is put at rest in a darkened room 
and an ice-cap is applied to the head. Attempt is made to determine 
which fossa is involved and whether the free interval of consciousness 
of middle meningeal hemorrhage occurs. If the sphincters have not 
been relaxed by the concussion a cathartic may be given, if the patient 
can swallow, and the bladder must be Avatched for overdistention. 

Further treatment is symptomatic until consciousness is regained 
and focal symptoms manifest themselves or until unconsciousness 
or delirium persist and a rising blood-pressure and other evidence of 
increased intracranial pressure is observed. Lumbar puncture for 
diagnostic purposes often proves of therapeutic value, and if increased 
intraspinal pressure is found and some relief obtained by drawing off 
the fluid, the procedure should be repeated up to four or five times 
within twenty-four hours. Rinderspacher has called attention to the 
value of the findings in lumbar puncture,^ and the importance of deter- 
mining the pressure and microscopical examination of the cerebro- 
spinal fluid immediately after head injury from a medicolegal stand- 
point. An increased pressure denotes a meningeal irritation or chronic 
serous meningitis, or an anatomical lesion within the skull, especially 
if accompanicfl by })loofl. Normal pressure does not disprove a cranial 
lesion, but if an increased pressure is found after accident, and later 
this subsides, the subsidence indicates that the increase had not kept 
up an irritating meningeal efi'ect. Neurasthenical conditions do not 
effect the pressure. 

' Fortschr. d. Med., 1914, xxxii, 405. 



208 FRACTURES OF THE SKULL 

The advisability of giving hexamethylenamine as a prophylactic 
against meningeal infection from bursting cracks at the base, is dis- 
puted, and it is difficult to draw satisfactory conclusions. Experimen- 
tally it has been determined that the formaldehyde gas is not given 
off unless the medium in which the hexamethylenamine is excreted 
has an acid reaction. If the patient can swallow it does not seem to 
do harm, and it may have a helpful effect. 

Operative treatment is primarily indicated in some cases. It is 
not necessary in those cases of mild concussion with no focal or 
increased intracranial pressure symptoms which seem certain of 
recovery. Likewise it is not necessary in the severer cases with great 
shock, fast pulse, deep unconsciousness and comminution of the skull 
with apparent irretrievable damage to the brain. These die in a 
few hours, or, if they do survive, the brain is hopelessly ruined. Treat- 
ment for them is care of the shock and a suitable aseptic dressing on 
the head. 

A bursting fracture of the vault which is of considerable extent 
with no indication of cerebral or dural hemorrhage nor other cranial 
injury does not demand exploratory operation. If linear fracture is 
present and if there is a hematoma beneath the scalp or marking the 
site of the contusion, the indication for operation is questionable, and 
the fact of fracture alone is immaterial. The cranial bones when 
cracked are not subject to displacement, as there are no muscular 
pulls exerted on them, and if death does not ensue, they heal quickly. 
Careful watching and rest, with study of the eye-grounds, increase in 
blood-pressure, decrease in pulse rate to, or below, 50 per minute, 
and manifestation of focal symptoms will furnish indication for 
craniotomy. 

A punctured fracture of the vault with depression of bones, hemor- 
rhage from within the skull, or the presence of brain tissue in the 
wound, calls, unless the patient is moribund or in great shock, for 
operative care at once. If the patient is unconscious, this can be given 
without anesthesia of any kind. The scalp wound is enlarged, its 
edges, if ragged and dirty, are trimmed clean, and, in simple depres- 
sion of the outer table, an effort is made to pry up the bone after it 
is loosened. If the inner table is found unbroken, the piece of outer 
table may be replaced or entirely removed and the wound closed with 
capillary drainage. If the inner table is found cracked and depressed, 
with no evidence of hemorrhage beneath, it also may be pried up into 
place, or one small fragment may be removed and the others lifted up. 
This is in no sense a decompression; it is in uncomplicated cases a mere 
reposition. This is excellent treatment if the injury is not over the 
motor area of the brain and the concussion is of short duration. In the 
frontal region one must be s'ure that the frontal or other sinuses are 
not opened into on account of the danger or infection. If they are 
concerned, free drainage must be kept in for several days until the 
cranial vault has healed on the inner side. 

Other depressed fractures may be tightly wedged or the bone may 



BURSTIXG OR RADIATING FRACTURES 209 

be driven down into the cortex. The treatment for these consists in 
making an opening in the immediate vicinity as in an operation for 
trephining, raising of the bone, arresting of diploetic and dnral hemor- 
rhage, and inserting of drainage. 

Gnnshot fractures and injuries of the skull and brain develop special 
indications according as they occur in civil life or in battle. Under 
the conditions of civil existence, they are cared for in accordance with 
the treatment for punctured wounds given above, with drainage and 
without operative procedure on the brain. In war, with poorer hos- 
pital and other service, conditions are altered. Friedrich^ classifies 
them as shallow injuries, caused by grazing or rebounding shots, and 
deep injuries caused by penetrating shots with or without wounds of 
exit. He also divides them into wounds of the base and of other 
regions of the skull. In severe comminuted injuries from penetrating 
shots immediate operation or attention by a skilled surgeon should 
be given on the field or nearby. It is not necessary to remove all 
bone fragments, but the skull should be spared as much as possible, 
and merely those lying free in the wound or pressing on the brain 
should be taken. Too active early interference gives poorer results 
than expectant treatment. Local anesthesia and morphine should b^ 
used in preference to general anesthesia. 

Except for local attention to wounds of exit and entrance, expec- 
tant treatment is indicated in injuries of the skull base, arising from 
penetrating shots and from grazing shots with cerebral hemorrhage. 
Symptoms of excess of intracranial pressure, speech disturbance, and 
other disturbances of focal character are also treated expectantly unless 
rapidly progressing. Even a technically correct early operation may 
not avoid infection, and the cause of most late increases in pressure 
is infection, which should be searched for and drained through one of 
the wound openings. 

A case of gunshot injury of the cavernous sinus has been recorded 
by Streissler.- The threatened loss of the eye on account of a neuro- 
paralytic keratitis and an abducens paralysis furnished indication 
for operation to remove the bullet, which was successfully performed. 

Non-puncturing Trauma of the Head; Bursting Fractures. — With 
or without Scalp Wounds. — In a certain percentage the indications for 
craniotomy are based on the following points: 

1. The violence of operation must not increase the damage already 
done. 

2. There must be reasonable possibility of relieving some or all 
symptoms. 

3. A fairly accurate diagnosis of the pathology present must be 
made on the symptoms and physical findings, and the lesion must 
be stationary or progressing; that is, muscular weakness must become 
paralysis and twitching become convulsions. 

IlartwelF believes that a further condition should })e imposed, 

1 Beit. z. Klin. Chir., 1914, xci, 271. 

2 Deutsch. Gesellch. f. Chir., 1914. ' Ann. of Surg., xlviii, 2-^. 
14 



210 FRACTURES OF THE SKULL 

namely, that one must be reasonably certain recovery will not take 
place without operation. The author does not agree with this any 
more than he would agree to a statement that no abdomen should be 
opened for an attack of appendicitis unless it were reasonably certain 
recovery would not take place. 

Immediate indications arise from progressive symptoms and signs 
enumerated above, practically all of which are caused by increased 
intracranial pressure. The early rise of pressure generally has its 
source in the extravasation of blood from injured cortical vessels; 
that coming later, accompanied by a free interval of consciousness, 
is probably caused by extradural meningeal hemorrhage, and the 
long-delayed symptoms usually by slow oozing from the cortex, or 
edema of the brain. This last group may take onset from twenty-four 




Fig. 54. — Decompression at site of head injury. Wound nine days after operation, 
drain removed, scalp sutures removed and wound healed. Recovery. 

hours after the injury and give prominent symptoms of headache, 
vomiting, and choked disk. 

Indications for decompression which are more remote are found in 
the rise of temperature and increase of cerebral tension with headache, 
etc., which denote abscess. Meningeal infections are usually quicker 
in onset and spread more rapidly, although it is impossible clinically 
to differentiate meningitis from cerebral abscess in an early stage. 
A cerebrospinal fluid containing evidence of pus and under increased 
tension is sometimes found in meningeal cases. Abscess may develop 
and give symptoms months after injury, and it must be suspected in 
cases of rapidly increasing evidence of mounting pressure and tem- 
perature. 

Epileptic attacks, paralysis, or chronic headache and threatened 



BURSTIXG OR RADIATING FRACTURES 211 

blindness from cranial changes and pressure are late indications for 
decompression and cerebral operation. 

Decompression can be performed at the site of injury, or at a point 
of selection according to symptoms of localized pressure or involve- 
ment of a known area of the cortex, as in paralysis or epileptiform 
attacks, or for general purposes in the temporal region, as advocated 
by Cushing.^ He enmnerates advantages of this last operation: 

1. Approach through the thinnest part of the skull 

2. Opening made under the temporal muscle, the fibers of which are 
split. When sutured it furnishes a good covering for the bulging 
cerebral contents. 

3. If the middle meningeal artery or its branches are ruptured, the 
extradural clot is brought into view and the vessel can be ligated. 

4. Subdural hemorrhage, from beneath the tips of the temporal and 
the base of the frontal lobes, which are most often injured, can be drained. 

5. A large percentage of the lines of bursting fractures seek the mid- 
cranial fossa; hence free bleeding from the base is most easily drained 
by gutta-percha under the temporal lobe through an approach via the 
temporal fossa. 

6. Subsequent edema and swelling of the brain which is responsible 
for most symptoms during the jBrst two weeks can be combated by 
this opening. 

7. Besides favoring an early subsidence of the acute symptoms, this 
operation lessens the late sequels and traumatic neuroses. 

Necropsy findings generally include severe damage to the inferior 
surfaces of the frontal lobe of the brain, but there is no gross evidence 
of injury sufficient to cause death, which must have followed on account 
of swelling and edema and resulting circulatory changes. Early 
decompression permits expansion of the brain within its tight envelope, 
and as swelling is sure to follow in brain tissue as in any other soft 
tissue during effort at repair, the operation should be undertaken 
more often as a prophylaxis than it is. The decompression favors a 
free circulation and accommodation to early and late hemorrhage. 

Blair^ attempted to verify the value of early decompression in dogs 
which were struck a measured blow on the head. His findings were 
that such animals not operated on showed basal clots, but those on 
which immediate subtemporal decompression was done did not have 
any })asal clots, or had none on the side which was drained. He also 
cites a series of 63 cases not operated on which lived more than two 
hours and of which 35 per cent, survi^'ed; while of 42 operated cases, 
o7 per cent, survived. 

Technic of Subtemporal Decompression. — One-half of the head, 
or only that ))art o\er the temporal region, is shaved dry and iodine 
applied. Either a curvilinear incision with the base downward or 
an oblique vertical incision is made in the temporal region. Hemor- 
rhage from the scalp is difficult to control })y ordinary methods as the 
opened vessels retract into the thick scalp and cannot be ])icked up. 

' Ann. of Surg., xlvii, 641, 

* Jour. Am. Med. Assn., Ixiii, 863. 



212 FRACTURES OF THE SKULL 

The whole thickness of the scalp must be caught in the forceps or some 
other means of hemostasis secured. An easy method is afforded by 
a heavy rubber tube stretched around the head just above the ears 
and tightened. This has a tendency to slip off or to get in the way of 
the base of the incision. Howzell's pressure forceps, one blade of which 
passes under the scalp, the other above, taking in a large area between, 
is also used. These are good, but are cumbersome and get in the way. 
Heidenhain's interlocking mass suture is also used, but is not fully 
efficient. Wood^ devised a rigid external metal frame to fit about the 
cranium, divided into quadrants united by hinged arms threaded 
with thumb screws. Within this, next to the scalp, is an inflated rubber 
tube with a valve stem like that of an automobile tire inner tube, 
coming out through a hole in the middle of the frontal rigid segment. 
On this is attached an atomizer bulb and a three-way cock for inflating 
and deflating. All parts can be boiled. Inflation of the inner tube 
compresses the scalp and stops hemorrhage; if slight oozing develops, 
a squeeze or two on the bulb controls it, and the constriction can be 
quickly removed by opening the cock. This is an improvement on 
Cushing's pneumatic clamp described in 1904. Landon^ has also a 
metal tourniquet broken fore and aft with a self-locking ratchet to 
tighten the band. 

The temporal muscle is exposed, split in the direction of its fibers 
and widely retracted. A trephine opening with the mechanical or 
hand drill is made, care being taken not to injure the dura, and the 
bone removed. A DeVilbiss forceps or the mechanical saw cuts off 
as much bone as is desired removed, extradural clots are lifted out 
if present, or hemorrhage is controlled by tying the middle meningeal. 
If hemorrhage from the diploe is uncontrollable, it may be stopped 
by Horsely's bone wax, or by bits of fascia or muscle taken from the 
operative field and jammed down into the bone. The Cryer spiral 
osteotome also controls hemorrhage from the diploe. If the dura is 
to be opened, it is wise to pick it up with a sharp, fully curved needle 
and a linen thread on either side of the proposed incision before 
cutting. This furnishes retraction and permits quick closure. The 
dura may be opened by multiple incisions. If hemorrhage is found, 
a thin, gutta-percha drain is inserted toward the base and brought out 
of the scalp wound, being removed in thirty-six hours. If no hemor- 
rhage is found, but increased intracranial tension is found, it is wise to 
do a similar decompression on the opposite side. The bone button is 
left out, the temporal muscle sutured over the defect, and the scalp 
closed, with a capillary drain of twisted silkworm gut at one angle. It 
is not necessary to go into the details of brain operations in this work. 

As a result of decompression with a small opening the dura and 
cortex bulge out strongly into the opening. They are protected 
by the temporal muscle and the scalp, and an enlargement in this 
area is not very noticeable. If decompression is done to relieve ten- 
sion, the opening must be made of sufficient size to give relief. It 

1 Ann. of Surg., li, 646. 

2 Surg., Gynec. and Obst., xviii, 95. 



BVRSTIXG OR RADIATIXG FRACTURES 



213 



has happened that edema with resulting paralysis results from a small 
area of cortex being caught in the bone hole. To a\'oid this, Hudson^ 
advised a large scalp opening with a similarly large bone flap, quadri- 
lateral in shape, cut through. This may be large enough to decompress 
a whole hemisphere. The bone is left and is held to the rest of the 
skull by small loops of silver wire inserted through drill holes and 
tightened to give slack, so that when the bone flap is extended to the 
limits of the wires there will be ample decompression. The scalp is 
closed over all. As the intracranial tension subsides the bone tends 
to come back into place and unites with a fibrous union. 




Fig. 5.5. — Decompression leaving the bone flap in place held by wire loops. Note 
the trephine openings connected by planes of separation made by the bone drill. This 
boy is alive and well, ten months after operation, and I believe is getting adherence 
between skull and bone flap. The unseen trephine openings are not on the opposite 
side of the skull, but seem to be on account of the angle of the roentgenogram. The 
longitudinal sinus was not opened. 

Results of early decompression in accordance with the indications 
are becoming more encouraging. HansohoflF,^ in 16 operations within 
twenty-four hours after accident, had 11 deaths and 5 recoveries. 
C'ushing-"^ had 2 deaths out of 15 decompressions, the 2 fatal ter- 
minations probably caused by the fact that unilateral exploration 
alone was performed. Lumbar puncture should be persisted in if it 
gives relief. Quenu reports 1 case"* in which spinal puncture was 
performed on eighteen successive days with recovery. Ransohoff 
found that 37 per cent, died within six hours or less and 56 per cent, 
flied within twelve hours, the fatalities occurring in spite of treatment. 



Ann. of Surg.. Iv. 744. 
Johns Hopkins Bull., xix, 48 



2 Ann. of Surg., li, 796. 

* Bull, et mem. Soc. de C;hir. 



N. S.. xxxi, 88.3. 



CHAPTER IX. 
FRACTURES OF THE BONES OF THE FACE. 

FRACTURES OF THE NASAL BONES. 

Anatomy. — ^The two oblong-shaped nasal bones lie in the middle of 
the face and form the bridge of the nose. They articulate above with 
the nasal notch of the frontal bone, laterally with the frontal process 
of the maxilla and below with the lateral cartilage of the nose. In 
the midline they articulate with each other. In addition they have 
anatomical relation with the vomer, the cartilaginous nasal septum, 
and the perpendicular plate of the ethmoid. 



Lachrymal 




Loioer lateral 
cartilage 



Fig. 56. — Side view of anatomical relations of the nasal bones. 

Pathology. — ^The line of fracture usually involves both bones, and 
sometimes the neighboring bony processes. Many of the fractures 
are open either on the skin or on the mucous membrane surface. The 
line of fracture may be oblique or transverse, or, as in most cases, 
comminuted or multiple, the lower part of the bone suffering most. 
The displacement varies. The two nasal bones may remain united 
and may be separated from the frontal bone and displaced upward or 
more commonly downward and spread out. If they separate, they 



FRACTURES OF THE NASAL BONES 



215 



extend laterally in direction of the cheek. Rarely one-half is fractnred 
alone, or is separated at the jnnction with the frontal bone and dis- 
placed laterally or iipwartl. The lateral cartilages are frequently 
loosened from the nasal hone and displaced, with injury also of the 
septum cartilage. 

The cartilaginous septum may be torn from the vomer or from its 
attaclmient to the superior maxilla. It may also be broken in its 
body and thrust out into the nasal canal. Spontaneous septal deflec- 
tions caused by fracture are likely to be angular, and they are later 
associated with cartilaginous or bony growths at the site of fracture. 
Most of the fracture lesions are located in the posterior two-thirds of 
the cartilage or the anterior half of the nasal bones. If the fracture 




Lower lateral cartilages 
Fig. 57. — Front view of relations of the facial bones. 



is greatly comminuted, both nares may become occluded by masses 
of bone or cartilage. This occlusion in children, after neglected nasal 
fractures, causes the patient to become a constant mouth-breather, 
with resultant changes which involve the teeth, palate, and jaws, as 
well as the chest development. 

When the nasal bones are much displaced, the upper cartilage 
usually deviates with them, but the bone also may be displaced. 
Horizontal or oblique fractures are more common than vertical. 
Hematoma formation beneath the perichondrium of the septum is a 
common accompaniment of the fracture. 

Infection from the skin or mucous membrane openings is frecjuent 
and leads to abscess, osteomyelitis with prolonged sup})uration, and 



21(i 



FRACTURES OF THE BONES OF THE FACE 



cartilage (lestruction. The hematoma of the septmn may become 
infected and cause late nasal abscess. Extension or complication of 
fracture into the cribriform plate of the ethmoid may cause interference 
with smelling sense, meningitis, or brain abscess. Emphysema involv- 
ing the subcutaneous tissues of the nose, cheeks, and eyes may be 
caused by penetration of fragments into the tissues. Rarely the lacri- 
mal duct may be occluded by pressure of an inflammatory process, 
or by bone fragments. Later nasal obstructions from septal deform- 
ities and inflammations are often seen. All the facial bones or those 
on one side may be fractured (see Fig. 58) . Powers reported a case. 




Fig. 58. — Fracture of one whole side of the face. Note the separation of the orbit 
zygoma, superior maxilla, and hard palate. Perfect recovery without infection. The 
cleft in the palate apparently healed promptly. Patient returned in a few weeks with an 
abscess of the face. 



I have had 2 cases. One was unilateral with the line of fracture 
through the hard palate, superior maxilla, zygoma, and orbit. The 
whole side of the face was freely movable, with crepitus. There was 
ultimate bony union and complete recovery with practically no defor- 
mity. Many of these severe accidents are caused by headlong pitches 
on the face in bicycle falls or automobile collisions. Korte^ records 
a case and calls attention to the serious character of the type, on 
account of possible meningitis. 

Symptoms. — Pain, hemorrhage from the nose, deformity and swell- 
ing follow in order after fracture. The primary deformity, caused by 

1 Deutsch. med. Wchnschr., 1913, p. 253. 



FRACTURES OF THE NASAL BONES 217 

misplaced frapiieiits, is often quickly enhanced by the subcutaneous 
swelling of hemorrhage into the injured area, which obscures definite 
deformity. Crepitus is usually- felt when the nose is grasped gently 
and manipulated. Emphysema of the tissues may develop, or the 
lacrimal obstruction may cause an epiphora on the affected side. 
There is obstruction in the nares, often with severe nosebleed, and 
intranasal deformity is found when the nose is examined by reflected 
light. The prognosis is good. The danger to life is small, what there 
is being mostly from infection and cerebral complication. Reposition 
and correction of deformity is often very difficult, so that the prognosis 
of deformity is under ordinary circumstances only fair. 

Treatment. — If there is severe nasal hemorrhage, the first step in 
treatment is to arrest this. Cold applications or sprays of adrenalin 
chloride solution, 1 to 1000, may be used, and if they fail the nares 
are packed with narrow gauze strips or plugged from the rear by 
gauze. Deformity of the cartilaginous septum must be ascertained. 
This is done by cocainizing the nares and examining wdth reflected 
light. Gross deformities of the septum and bones demand prompt 
reduction and general anesthesia is often necessary. The§e bones 
unite quickly, and angles formed by misplaced fragments fill up with 
blood-clot and exudate which prohibit delayed reduction after a week. 

To accomplish reduction the surgeon places his left hand and fore- 
finger on the deformed bridge. He inserts a flat, narrow periosteo- 
tome into the nostril on the side of the greatest deformity and elevates 
the nasal bone on that side into position. I frequently use a Kocher 
director in adults. The other nasal bone is dragged into place by the 
adhering tissues and they are both approximated in the middle by 
gentle pinching with the fingers of the left hand. The displacement 
will not tend to recur often except in cases of great comminution or 
in severe injuries of the septum. If the bone will not remain in place 
attempts may be made to hold it up by packing the nares with gauze. 
This holds the fragments up from within, and externally little splint- 
ing is required, as the tendency to displacement does not come from 
external source. External splints to correct lateral angulation have 
little value. Tin may be moulded to fit the nose and forehead for 
holding the alignment of the bridge, but there is always danger of 
compression on the secondary swelling, and the splint cannot be 
steadily maintained. The head portion is fastened by a head band, 
but it tends to slip and requires frequent adjustment. Cobb's splint 
consists of a metal head band held on by straps with an adjustable 
arm attached to a swivel like a head mirror. This has a padded 
extremity which makes counter-pressure on the displaced side of the 
nose. It is open to the objection made to any splint which produces 
pressure. When displacement cannot be retained by simple means, 
attempts to reduce the deformity should be repeated until success 
follows after the acute swelling begins to subside. Open operation 
is rarely indicated, but intranasal bracing or })lugging with gauze is 
justifiable. 



218 FRACTURES OF THE BONES OF THE FACE 

The internal deformity involving the septum and nares is as impor- 
tant as the external. Internal examination will assure the surgeon 
that the septum is in good alignment; if it is not, it should be replaced 
and the anterior nares packed to hold it. If there is great swelling 
or tendency to hemorrhage, it is better to give a guarded prognosis, 
let the septum heal, and look forward to a later submucous resection 
by competent hands. If there is suppuration the nose must be irri- 
gated several times a day by a mild alkaline antiseptic wash to keep 
it clean and to favor free drainage. Secondary abscess in the cartila>ge 
or posterior nares must be drained and irrigated. 

Old fractures of the nose are treated either by intranasal operation 
or by an opening through the skin externally below the bridge. A 
small longitudinal skin incision permits retraction upward to allow 
a narrow chisel to cut through the ascending process of the maxilla 
and the base of the nasal bone. Both sides are freed and the bones 
are pushed up into place, if they are flattened out. A projecting edge 
of the maxilla which causes deformity is also chiseled off through 
the original skin opening. 

FRACTURES OF THE MALAR BONE. 

Fractures of the malar bone are not frequent. I have had four 
in the last two years, two of which were operated on. In Cook County 
Hospital in the last eight years there have been seventeen fractures 
of the malar bone. 

Anatomy. — ^This bone is exposed to violence on account of its posi- 
tion, but its flat surface, its thick body, and its four supporting pro- 
cesses give it great strength. Extending posteriorly is a strong process 
which unites with a similar process from the temporal bone to form 
the zygomatic arch, which is the strongest support the malar bone has. 

The malar bone is injured by direct violence from blo,ws or kicks 
on the face. The fracture may involve the body alone, as a depression 
or linear crack, the suture lines connecting neighboring bones may be 
disrupted, or the adjacent structures, especially the superior maxilla, 
may be fractured at the same time. The zygoma is also often fractured 
alone and the frontal bone, the base of the orbit, and other structures 
may be involved. Stimson^ mentions 2 cases of fracture of the 
zygomatic arch from within outward by falls on sticks held in the 
mouth. Rarely the temporomaxillary joint is involved, and the 
coronoid process of the mandible is broken. 

Symptoms and Diagnosis. — Although the bone is subcutaneous, it 
is difficult to palpate because it merges with surrounding bone. Both 
cheeks should be examined simultaneously, the surgeon standing 
behind the patient to feel the zygomatic arches. The facial skin 
and tissues are freely movable upward, and the malar process of the 
superior maxilla, the lower border of the orbit, and the zygomatic 

^ Fractures and Dislocations, 1912, p. 174. 



FRACTURES OF THE MALAR BONE 219 

process of the frontal bone can be all outlined. By comparison of the 
two sides variations in the position of the interlying malar bone can 
be made out, the lower border being also palpable by fingers hooked 
under it back to the temporomaxillary joint. 

Deformity caused by depression or lateral displacement of the 
bone with swelling, mobility, and crepitus are the diagnostic symptoms. 
The ecchymosis and swelling about the orbit may obscure these find- 
ings for a few days, or if the fracture is open the loss of bone continuity 
may be seen, or felt by a probe. Function of the jaws is seldom 
interfered with unless there is fracture of the coronoid of the mandible, 
but there is usually some pain in mastication because of proximity 
to the insertion of the masseter muscle. Mobility of the bone and 
crepitus can be detected by one grasping the zygomatic arch on the 
inferior margin and rocking the bone. If there is a diastasis or linear 
crack, no crepitus will be obtained. Cracks and separations extending 
into the orbit may be palpable, or the overlapping displacement of the 
malar bone on to the superior maxilla may form a definite palpable 
ridge, as in one of my cases. 

^Mien the displacement pinches the infra-orbital nerve, or the superior 
maxillary nerve is bruised, there is pain or anesthesia in the face, lip, 
and teeth corresponding to the nerve distribution. The same symp- 
toms are produced by the pressure of extravasated blood and swelling, 
w^iich may also displace the eye. If the superior maxilla is involved 
in the fracture, the maxillary sinus may be opened, and there is 
hemorrhage from the nose with danger of secondary infection. The 
bone tends to unite quickly and with little callus. Deformities remain 
permanently unless reduced, and the question of treatment rests 
almost entirely on the displacement or the symptoms of nerve pressure. 

Treatment. — Open fractures must be cleansed and drained, and 
small loose bone fragments must be removed. Replacement can be 
done at the same time, and a retentive dressing holds the bone in 
place, particularly when the zygomatic arch is broken. Depressions 
are very difficult to raise without open operation. The use of hooks 
inserted subcutaneously has been suggested, but they are unsatis- 
factory. When there is deformity in the zygomatic arch or at the 
junction of the superior maxilla, or a depression deformity with 
interference with jaw function for any reason, open operation is indi- 
cated. Gibson reported a case^ in a man of twenty-two years, who fell 
against a sharp object. There was immediate limitation of move- 
ment of the lower jaw, which was recovered from after open operation 
and reduction of the malar fracture. Likewise, nerve pressure with 
sensory disturbances of the teeth indicate open operation, but not until 
time has elapsed to permit a})sorption of extravasated blood which, 
instead of bone, may have been the cause of pressure. 

Open operation means a scar on the face, and the patient should 
make a choice between the bone deformity and the skin scar. If the 

' Ann. of Surg., Iv, 457. 



220 



FnACTURES OF THE BONES OF THE FACE 



zygoma alone is fractured and depressed, it may be raised by a narrow 
chisel or periosteotome through a quarter-inch incision parallel to and 
below the arch. A wire suture passed under the fragment may permit 
it to be elevated into position. When the whole malar bone is depressed 
or there is deformity involving the function with the superior maxilla, 
it is almost impossible to raise the fragment except by open operation. 
Involvement of the maxillary sinus may permit the elevation of bone 
by an approach through the mouth, an opening into the antrum and 
the prying up of fragments from within. There is little tendency to 
recurrence of deformity, and the only care needed is to avoid pressure 
on the bone until union has followed. This takes from two to three 
weeks. Old cases with depression and union or nerve involvement 
sometimes come for operation. In these I make a small curved incision 
over the junction of the malar and superior maxillary bone and raise 
a flap of soft parts. If there is solid bony union, the depression cannot 




Fig. 59. — Result after an open fracture of the malar bone. The scar became adherent 
to the bone, pulling the lower lid down so that the eye could not be closed. Cured by 
operation to free the adherence. 

be raised, but deformity caused from overlapping edges of either the 
malar or superior maxillary can be trimmed down level by a chisel. 
When the supra-orbital nerve is pinched by bone, the canal is widened 
by the cutting away of a trough and pressure is thus relieved. 



FRACTURES OF THE SUPERIOR MAXILLA. 

The superior maxilla is irregularly shaped and bound to the con- 
tiguous bone as the malar bone is. It has strong borders which come 
in contact w^ith the malar by the malar process, with the frontal, 
zygomatic arch and orbital bones, by corresponding processes. The 
body of the bone is w^ell protected ; its surface plates are thin and they 
form the boundaries of the maxillary sinus, the upper border of which 
lies at the malar process of the maxilla. Direct violence is the general 
cause of fracture, and other bones are often involved. The anterior 
wall of the antrum may be caved in by a blow, or the alveolar process 



FRACTURES OF THE SUPERIOR MAXILLA 221 

may be broken in the exertion of pulling teeth. The palatal suture 
may be separated with diastasis of other sutures. The malar bone is 
frequently driven down and impacted into the maxilla. 

The infra-orbital or anterior dental nerves may be involved in the 
maxillary fractures, and hemorrhage from the nose is common when 
the antrum is broken into and its mucous membrane torn. Indirect 
violence is also a cause, from violence transmitted through the inferior 
maxilla, which forces the superior maxillae apart. Brown^ cites a 
case of his own and one of Dr. G. W. Fox's of Milwaukee. In the 
latter 's case there was an opening through the incisor teeth and hard 
palate and division of the soft tissues caused by the forcing apart 
of the maxilla?. The zygomatic-maxillary suture also was disarticu- 
lated, and the examination by palpation revealed diastasis in the 
infra-orbital area. 

Symptoms and Diagnosis. — There is often depression, pain, swelling, 
and nasal hemorrhage. These facial fractures occur from a mechanism 
which tends to drag them away from the skull rather than depress 
them into it, but rarely the superior maxilla may be deeply driven in 
and backward toward the pharynx. If the injured person is seen before 
the extravasation of blood and swelling an early diagnosis may be 
made by palpation, as described under the Malar Bone. Crepitus is 
often lacking. Ecchymosis in the hard and soft palates indicate frac- 
ture. There is always ecchymosis with involvement of the eye, and 
the swelling may be great. ]Many fractures are overlooked, however, 
until they have united. They are then determined by the deformity 
of the dental arches. Mastication is painful from involvement of the 
masseter and pressure of the temporal muscle. Intra-oral examination 
should be made that narrowing or dropping of the dental arch may be 
determined. 

Treatment. — Some of these fractures are open on the skin surface, 
and they should be treated as are open fractures in any part of the 
body, by asepsis and drainage. The facial bones have an abundant 
blood supply, and it is best to leave in situ any loose fragments of 
bone, because they usually remain viable. PVactures opened from 
within the mouth through the mucous membrane, particularly those 
involving the alveolar margin, are also treated conservatively. An 
antiseptic mouth wash is provided. And, if the fragment cannot be 
held in replacerqent, the teeth may be wired or fastened by the inter- 
dental splints described under the Fractures of the Inferior Maxilla. 
Xo attempt should be made to withdraw loose teeth, because they 
often become firmly fixed in the sockets later, and traction on them 
may break ofl' a portion of the fractured alveolar border. This break- 
ing off opens up the bone surface to further chance of infection and 
must be avoided. Open fractures furnish opportunity for direct 
replacement of fragments. Wires to hold them are seldom indicated. 

The course of closed fractures is one of considerable discomfort 

1 Oral Diseases and Malformations, 1U12, p. .378. 



222 FRACTURES OF THE BONES OF THE FACE 

because of the contusion character of the injury with the impaction 
of the bone. If the nerves are pinched, there is acute pain which calls 
for immediate reduction or the use of anodynes. After the swelling 
subsides the facial asymmetry is noticed, and untreated cases result 
in deformity. Complications from abscesses in the cheek or infra- 
orbital fossa, or empyema of the maxillary sinus are not common. 
They demand drainage and hot applications with vaccine therapy. 

If the fracture can be reduced, the simplest treatment is to hold the 
jaws together by wiring or interdental splints. The dentist's modeling 
wax is heated in warm water, and after the bone is replaced the jaws 
are brought together on the wax, which when hardened acts temporarily 
as a splint. (See Fractures of the Inferior Maxilla.) A rubber or 
metal dental splint should be made subsequently by the dentist. 

Some fractures are irreducible by manipulation and dental splints. 
These patients are also offered the alternative of deformity or open 
operation, but facial scar is not always necessary. The same external 
operative measures are used as were described under Fracture of the 
Malar Bone. The depression may be lifted into position by hook or 
wire and the fragments wired to each other. Usually all that is needed 
is replacement, with a slight impaction to hold the maxilla in position. 
Efforts to raise the superior maxilla by means of an instrument used 
inside the mouth are not very successful. That method will raise 
the zygomatic arch or the malar bone, but it fails to hold up the 
maxilla. Lathrop^ recommends approach via the canine fossa, citing 
7 cases treated in that way. He used general anesthesia administered 
through a nasal tube, the patient sitting erect. The nasal and maxil- 
lary fragments are elevated through a small horizontal opening in the 
mucous membrane on the canine fossa when the cheek is held back. 
If there is a fissure present in the bone, a narrow director is passed into 
it; if no fissure is present, an opening is made into the antrum, and 
a No. 24 French sound is passed in to force the bone into position. 
The antrum is then packed with a narrow strip of iodoform gauze to 
hold the fragments in position and to insure drainage. This is removed 
in four or five days, and the antrum for a few days is irrigated by an 
antiseptic wash through the mouth. 

After-treatment, especially that directed toward feeding and oral 
asepsis, is very important. Most of these injuries are accompanied 
by shock of serious extent and this must be combated by stimu- 
lants and careful nursing. If the palate is split asunder, swallowing 
may be impossible, and all food must be given by a stomach or 
nasal tube. The nasal tube is better, as it leaves nothing to soil the 
mouth. When the patients are able to attend to themselves, order a 
glass to be kept filled with antiseptic mouth wash for their use every 
hour. Food should be kept out of the mouth when there is an opening 
into the facial bones> and a nurse should irrigate every two hours. 
(For nasal feeding see Fractures of the Inferior Maxilla.) Secondary 

1 Boston Med. and Surg. Jour., .January 4, 1906, cliv, 8. 



FRACTURES AND DISLOCATIONS OF INFERIOR MAXILLA 223 

abscesses and osteomyelitis sometimes prolong the case. Sufficient 
drainage must be instituted, and every precaution taken to insure 
oral cleanliness and to ward off pneumonia. 

FRACTURES AND DISLOCATIONS OF THE INFERIOR MAXILLA. 

In 10,702 fracture cases admitted to the Cook County Hospital in 
eight years, 437, or 4 per cent., were fractures of the inferior maxilla. 
Dunning^ gives a tabulated list of 1065 cases treated at the New York 
College of Dentistry, and he found that 28 per cent, of the cases 
occurred in the third decade of life, while 32 per cent, occurred in the 
fourth decade. ]Males predominated over females in the proportion 
of 992 to 73, approximately 93 per cent, to 7 per cent. These facts are 




Fig. 60. — Double fracture of the inferior maxilla, one plane near the symphysis, the 
other just back of the teeth. 

readily understood when one considers the exposed location of the 
bone, the occupations of men, and the frequent settling of disputes by 
fisticuffs. In Dunning's series fist blows accounted for 495 cases, or 
46.5 per cent., falls for 140 cases, or 13 per cent., extraction of teeth 
for 5 cases, or 0.5 per cent., and pathological fractures for 2 cases 
out of the total number, or 0.2 per cent. Children rarely suffer frac- 
ture of the jaw. Fracture of the alveolar border, the pulling off of 
a small edge or splinter of bone, is a common result of tooth extrac- 
tion and is not included in statistics. Complete fracture of the jaw 
caused by tooth extraction is relatively rare. 

Double fractures on the same side or half of the bone are a little 
more frequent than on corresponding points of the two halves (Fig. 
60). They are more painful and are often accompanied by partial 

' Jour. Amer. Med. Assn., January 9, 191.5, Ixiv, No. 2. 



224 FRACTURES OF THE BONES OF THE FACE 

dislocation if the two fractures are symmetrical and the bone arch 
loses its support. This permits the condyles to be partly displaced 
from the glenoid cavities. Single fractures predominate numerically, 
triple and quadruple fractures occurring rarely. In the 1065 fractures 
mentioned previously there was the following division : 

Single fractures 951 or 89.0 per cent. 

Double fractures 108 or 10.0 

Triple fractures 5 or . 5 " 

Quadruple fractures . . lor 0.1 " 

Fractures of the inferior maxilla may be divided into those of the 
body, median line or symphysis, ramus, alveolar border, condyloid 
process, and condyle. In the body and at the symphysis, the site and 
direction of fracture plane is guided by the direction and force of 
the causative direct violence and the presence or absence of teeth or 
foreign bodies held between the teeth (Fig. 63). 





Fig. 61. — Fracture through the body of Fig. 62. — Fracture through the body 

the jaw. Note the loosened tooth. of the jaw. The plane of separation has 

selected the alveolar process bearing a 
tooth. 

The site of fracture is commonest in the canine and bicuspid region 
of the body of the bone. The weakest point is about the mental 
foramen, especially in an edentulous jaw. This point is the one where 
most blows land and is also weakened because many people lose the 
bicuspids or molars early in life. The ramus, symphysis, coronoid 
process, and condyles are less frequently involved. Impacted teeth 
in the mandible predispose to fracture at their location and they also 
hinder bony union. They are easily found by the Roentgen rays. A 
very large proportion of jaw fractures are open. Most are opened into 
the mouth through the gums and mucous membrane, which forms a 
scant covering over the bone, and which is easily torn when the teeth 
are displaced. 

The displacements vary with the site of fracture. In the body the 
fractures through the canine region do not show much deformity but 
they are frequently obstinately displaced. In this region there is 
little opportunity for diverse muscle pull when the fracture is so near 
the midline, but the line of fracture is often oblique, and the fragments 



FRACTURES AXD DISLOCATIOXS OF IXFERIOR MAXILLA 225 

tend to slip past each other if not firmly supported. Displacement in 
the bicuspid region may show marked deformity, as the anterior 
fragment tends to be pulled downward and backward by the hyoid 
muscles, and the posterior fragment is drawn upward by the masseter 
and pterygoid muscles. The same facts regarding displacement apply 
to the fractm^es in the molar region, which usually exhibit deform- 
ity. These injuries are likely to pinch or lacerate the inferior dental 
nerve. 

Fractiu-es back of the teeth are not common. Through the angle 
of the jaw they are oblique from above downward and backward. In 
the ramus the fracture is also oblique or vertical, depending on the 




Fig. 63. — Incomplete jaw fracture through a lone tooth, the jaw being quite edentu- 
lous. There is no separation. 

character of the causative blow. Displacement is limited by the strong 
supporting muscles on either side. 

Fracture of the Condyle of the Inferior Maxilla. — The causes are 
direct violence, which drives the jaw backward and upward, or vio- 
lence applied directly over the side of the face. Fracture of this process 
is probably quite frequent and is solitary, not accompanied by injury 
of the other facial bones in all cases. Roe^ found six condyloid frac- 
tures in 41 cases examined by him, and Egger^ gathered together 365 
cases of simple fracture of the mandible of which 4.1 per cent, involved 



15 



Ann. of Surg., August, 1903, p. 221. 
Beitr. f. klin. Chir., 1913. Ixxvii, 294. 



226 FRACTURES OF THE BONES OF THE FACE 

the condyle. Multiple fractures of the lower jaw and of the facial 
bones involve the condyle more frequently, the percentage rising as 
high as 10, according to Egger. Dunning's figures show the condyle 
involved in less that 1 per cent. Ivy^ collected 45 instances of frac- 
tured jaw and found but 1 case of condyle fracture. Both condyles 
may be broken by the force. The anterior wall of the external auditory 
meatus may be crushed in, or the glenoid cavity of the skull may be 
cracked and depressed. When the ear canal is involved and the con- 
dyle is intact, there are symptoms of occlusion of the canal when the 
jaws are closed or the inferior maxilla is forced backward. If the glen- 
oid cavity of the skull is fractured, there is possibility of infection and 
brain abscess or ankylosis in the joint. Some effort should be made 
to determine whether the fracture is extra- or intra-articular, because 
the distinction has a bearing on both treatment and prognosis. Most 
condylar fractures are through the neck and are extra-articular, and 
there is little displacement, because the fragments are held, by the 
periosteum and surrounding ligaments and soft tissues. If both con- 
dyloid processes are broken, the lower jaw is drawn up and backward, 
and there may be considerable movement in the joints. There is 
continued pain and a tendency for the small fragments to necrose 
or become absorbed. Unilateral fractures cause swelling around the 
temporomaxillary joint, ecchymosis and pain from joint movement, 
and exhibit a mandible drawn toward the fractured side by the oppo- 
site internal pterygoid muscle. Crepitus can often be felt by a finger 
placed over the point of tenderness when the jaw is moved. Unilateral 
dislocation is distinguished from the unilateral condyle fracture by the 
fact that the jaw is pulled toward the normal side in dislocation. Other 
differential points between unilateral dislocation and condylar frac- 
tures are: in fracture there is crepitus, and the jaws can be closed, 
whereas in dislocation the jaws are open, there is no crepitus, and the 
chin is deflected away from the injury. In some cases the broken-off 
articular surface of the condyle may be displaced forward and inward. 
It is pulled upon by the external pterygoid muscle and can -be felt by 
one pulling the jaw forward, placing the finger in the upper lateral 
pharyngeal wall, and pressing outward. The portion of the bone below 
the process is drawn upward and outward by the masseter muscle 
(Fig. 64). Union may occur with this displacement without ankylosis, 
but with the chin deviated toward the injured side. Reduction accom- 
plished by the means mentioned may be satisfactory and permanent. 
These fractures go undiagnosed after falls followed by coma or uncon- 
sciousness. They are not noticed until the patient recovers to find 
that the teeth are not in alignment. 

Involvement of the temporomaxillary joint in intracapsular fracture 
influences treatment to the extent that moderate joint motion must 
be encouraged from the first to avoid ankylosis. Roy^ advises against 
the use of interdental splints in condyle fractures for fear of ankylosis. 

1 Ann. of Surg., Ixi, No. 4, p. 502. 

2 L'ondontologie, 1913, xlix, 481. 



FRACTURES AXD DISLOCATIONS OF INFERIOR MAXILLA 227 

If the smaller fragment is widely displaced, or if ankylosis threatens 
to ensue, the fragment should be excised and an atypical arthroplasty 
should be done at once with the use of any tissue in the neighborhood 
to cover the bare bone end. 

Fractures of the Coronoid Process. — Fractures of the coronoid 
process are rare, because it is protected from direct violence by the 
zygoma and from indirect violence by mobility. Whether fracture 
of this process may be caused by contraction of the temporal muscle 
has not been demonstrated. Usually fracture of other facial bones 
accompanies this injury. In Dunning's series there were two coronoid 
fractures. The dangers of joint ankylosis and treatment are like those 
of the condyle. 

Sjrmptoms and Diagnosis. — Fractures of the mandible have most of 
the cardinal fracture symptoms. Pain and tenderness are always 
present. There is abnormal mobility of the bone, which is easily 
apparent to both the patient and surgeon, and is proved by the lack 
of power in the jaw. Crepitus is present and is demonstrated either 




Fig. 64, — Fracture through the neck of the condyle of the mandible. 

by the attendant's taking the jaws between the fingers and moving 
them or by his having the patient bite. The patient feels the bone 
slip and has simultaneous pain. There are often hemorrhage and swell- 
ing in the external soft parts, from the trauma received or the tearing 
of the periosseous tissues. Within the mouth the line of fracture may 
be visible at a glance, the malalignment of the teeth showing promi- 
nently, and the bleeding, torn line of separation through the mucous 
membrane standing out. .There is increased salivation from reflex 
nerve stimulation or pain, drooling is present, and there may be a 
copious bloody expectoration. The' patient does not talk plainly, 
he cannot close the jaws firmly, and he very probably has loosened 
teeth. Double fracture causes greater deformity and loss of function, 
the broken-out piece tending to be drawn down and backward. After 
a couple of days, if infection has started, there is a foul })reath, pus 
exudes from the torn gums, and swelling and abscess at the site of 
fracture follow. Later there is an inflammatory infiltration of the 
neck and face tissues on the injured side, cervical adenitis l)egins, and 



228 FRACTURES OF THE BONES OF THE FACE 

the patient becomes more or less toxic from swallowing pus. Mas- 
tication is painful and is soon not attempted and there is sore throat 
and pain on swallowing. Deviation of the jaw depends on the site 
and multiplicity of the fracture, as previously described. Gunshot 
fractures from suicidal attempts when the bullet enters from the oral 
side, are characterized by loss of bone tissue and severe laceration of 
the soft parts. There is always great shock and hemorrhage. When 
the dental nerves are involved, there may be extreme pain from 
partial pressure, or anesthesia, when the nerve is severed or crushed. 
There is but one case on record of rupture of the facial artery in frac- 
ture caused by direct violence.^ 

Cases of jaw fracture of some days' duration always present swell- 
ing and edema with increasing pain. The gums are swollen, and a 
discharging sinus may lead to the bone, where there are loose and 
necrotic fragments of varying size. The fragments are not large as a 
rule, and extensive loss of bone from infection is uncommon. Even 
in the presence of infection bony union occurs in four to six weeks. 
Secondary abscesses, sinuses, or discharge of necrotic fragments may 
have occurred in the course of the recovery, but non-union is very 
rare. I have had a case of double fracture this year, one line passing 
obliquely through the bone at the angle, the other through the sym- 
physis. Operation was performed on the posterior fracture, and the 
symphysis was held by a bandage. After eight weeks when the angle 
was firmly healed, the symphysis still permitted motion. Union 
finally occurred. In Dunning's series of 1065 cases there were but 
2 cases of non-union. 

Prognosis.— The prognosis is favorable in most cases. When other 
facial bones are injured, there is danger of serious shock. There are 
other dangers from pneumonia, brain abscess, and general sepsis 
from swallowing and absorbing the pus secretions in the mouth. Even 
with abscess formation and bone infection the outlook is favorable 
with efficient drainage. 

Treatment. — Because infection is the main thing to be considered 
in all fractures of the jaw, even in the small percentage of closed cases, 
first attention should be directed toward oral cleanliness. To obtain 
this, as well as to carry out the best line of treatment, the services of 
a dentist should be secured. Closed cases are likely to become open 
by pressure of bone fragments, sloughing of gums and mucous mem- 
brane, or loosening of teeth in the fracture area, and every case of 
mandibular fracture should be prepared with a view to the care of 
infection locally and generally. The teeth must be carefully cleaned, 
and old loose and infected roots should be removed, if there is not 
too much pain in the jaw. The patient should use an alkaline anti- 
septic mouth wash if he is able, cleansing the mouth out gently every 
hour. W'hen other injuries or the general condition renders this 
cleansing impossible, the attendant should wipe off the teeth with 
soft cotton swabs every two hours. The mouth wash reduces the 

1 Cramp, Med. Rec, New York, September 21, 1911. 



FRACTURES AXD DISLOCATIOXS OF IXFERIOR MAXILLA 229 

bacterial activity, soothes the swollen iiuicous membrane, and i)ro- 
motes drainage of sinuses. AVhen infection is established in the bone, 
hydrogen dioxide must be added to the irrigating solution. Fractures 
opened by external wounds through the soft parts of the face are 
drained and partly closed after thorough cleansing. The facial tissues 





Fig. 65. — Beginning of the second 
turn of Barton's bandage. 



Fig 06.- 



-Gibson's bandage for 
the jaw. 



are so vascular that they are able to overcome infections which would 
get the better of other tissues. In ordinary practice after mouth 
cleansing has been started we apply a flat ice-bag to the side of the 
face and hold the jaw in a partly restricted and comfortable position 
by a bandage. 

Further treatment is divided among the following procedures: 
1. External bandage and splints applied to the head and jaw, such 
as Barton's bandage, wire splints, plaster-of-Paris dressings, and 





Fig. 07. — Crossed bandage of the face 
used for mandibular fracture. 



Fig. 08. — Plaster-of-Paris bandage for 
fracture of the mandible. 



various other retentive splints to hold the jaw externally (Figs. 05, 
00, 07, and 08). 

2. Efforts to effect dental occlusion by wiring the teeth, temporary 
and permanent interdental sy)lints, and a combination of internal and 
external splints like Matas's. 



230 FRACTURES OF THE BONES OF THE FACE 

3. Surgical operative procedures consisting in wiring the body of the 
bone or ap})lying other types of internal bone splints. 

Laying aside the necessity of oral cleanliness outlined previously 
we must select a type of treatment which aims at immobilization, 
perfect approximation of the fragments and dental alignment, oppor- 
tunity for taking food and possibility of inspection of the parts. To 
these desirable features one might add a provision for some freedom 
in the use of the jaws, but that is not essential. The most important 
function of all is perfect dental occlusion, so that the patient may 
retain his bite and mastication power. Carmody^ states that over 
200 methods of treatment have been devised for fracture of the jaw. 
Only a few of known worth will be described. 

1. External bandages in ordinary use are Barton's and the four- 
tailed bandage. They must be watched to prevent slipping and stretch- 
ing. For preliminary treatment they offer much comfort and a sub- 
stantial support. Other external splints made of wire or metal are 
padded to fit outside the lower jaw and are strapped or bandaged into 



Fig. 69. — Angwin's method of wiring the teeth for fractured mandible. 

position. The dentist's modeling compound may be moulded to fit 
the outside of the jaw and held on by bandages. Alcoholic patients 
who will not keep a bandage on can be dressed with broad bands of 
adhesive around beneath the jaw and over the top of the shaved head. 
2. Wiring the teeth, that is, wiring the teeth of the two jaws together 
to hold all in position, is an old procedure. Gilmer first described 
it in 1887.2 There are many methods of doing this, in all of which 
precaution is taken to avoid putting stress on the teeth which approxi- 
mate the fracture site lest they be loosened. More distant teeth are 
selected, and the wires, copper or German silver No. 24 gauge, are 
anchored around the base and twisted into a long strand on the outer 
surface. These long strands are then twisted together from above 
downward across the fracture site to hold snugly, with the cut-off 
ends bent in toward the teeth. The dental alignment should be per- 
fect, and the wires will need watching and tightening. They should 

• Military Surgeon, 1914, xxxiv, 542. 

2 Areh. of Dentistry, 1887, p. .388; and International Congress, 1904, p. 185. 



FRACTURES AXD DISLOCATIOXS OF INFERIOR MAXILLA 231 

remain in position thirty to forty days. The disadvantages are that 
the patient has to snbsist on Hqnid diet which he sucks through his 
teeth, and that the teeth are Hable to loosen under the continued strain. 
A very excellent method of wiring has been described by x\ngwin/ for 
illustration of which see Fig. 69. 




Fig. 70. — Splint for fractured lower jaw. (After Angle.) 

The greatest objection to Angwin's method is the wiring of the 
central incisors, which I have found in some cases impossible. 
Angle's bands are also a similar and possibly better method of hold- 
ing the jaw in corrected position. They are bolted on (see Figs. 
70 and 71. Figs. 72 and 73 show Angle's and Loher's splint). If the 




Fig. 71. — Splint for fractured lower jaw. (After Angle.) 

jaws are wired while the patient is under the influence of a general 
anesthetic, the nur.se should be provided with a pair of wire clii)pers 
to be used if there is a postanesthetic vomiting. Suffocation and 
aspiration pneumonia are the dangers. 



' U. S. Navy. Med. Bull., Wa.shington, 1911, v, 332. 



232 



FRACTURES OF THE BONES OF THE FACE 



After wiring of the jaws the patient may be fed by means of a small 
rubber tube passed along the gum margin to a point behind the teeth. 
Nasal feeding, as performed in gavage on children, is also practical and 
causes no inconvenience if the patient cooperates. A rubber tube is 
needed, small enough to enter through the nostril. It is passed in 




Fig. 72.— Splint for fractured lower jaw. (After Angle.) 

well lubricated after a cocainizing of the anterior nares with 5 per 
cent, cocaine solution. When the tube enters the esophagus liquid 
food is slowly passed in by a small glass funnel held above the level 
of the highest bend of the tube. After the feeding is completed, the 
tube is washed out with sterile water and then withdrawn. This 




Fig. 73. — Loher's splint. (Brown.) 



prevents contamination of the nares with food. Through a com- 
bination of nasal feeding and constant lavage of the mouth the oral 
infection is reduced to a minimum. 

Temporary interdental splints are made of dentist's modeling 
compound, which should be at hand in every hospital. This compound 
is softened in warm water, a suitable piece is placed between the jaws, 
and the teeth are closed on it. The' jaw is brought into alignment. 



FRACTURES AXD DISLOCATIOXS OF INFERIOR MAXILLA 233 

but the inoutli need not be closed. After the impression is made, the 
compound is removed and allowed to harden fully. A hole is cut out 
of the middle through which food and liquids can pass. The splint 
can be used permanently if one takes the precaution to use cold solu- 
tions for feeding and irrigating the mouth. Warm fluids soften the 
compound and change its shape. 

Permanent interdental splints, that is, supports placed between the 
jaws, were first used by Hay ward in 1858. Reduction and perfect 
alignment of the teeth are necessary before they are fitted. Indi- 
viduals who have multiple fracture or who have much pain and are 
very nervous may require a general anesthetic preliminary to reduc- 
tion. With the fracture reduced if possible, an impression of the teeth 
is made with the modeling compound. This is removed and hardened, 
and plaster cream is poured into the mould. This gives a plaster cast 
which represents the exact condition of the teeth. After it has hard- 
ened the plaster may be sawed through at the fracture site if reduction 
is not perfect and the alignment of the plaster cast is corrected. Over 
the plaster is fitted a rubber or metal splint which can be cemented 
on to the teeth to hold the jaw perfectly reduced. With this apparatus 
the mouth can be opened and soft food can be eaten. 

There are some soft interdental splints w^hich have arms and pro- 
longations externally for fixation by bands around the head or neck. 
Kingsley's interdental splint is an excellent one (see Figs. 74 and 75). 
Green^ describes an external internal splint to give fixation to the 
jaw without the use of bandages. 

Matas's splint^ is a combination of interdental splint and external 
chin support which can be bandaged on (see Figs. 76 and 77). 

Gunshot fractures which cause loss of bone continuity can be held 
in position by a dental bridge splint on the injured jaw. Patterson^ 
cites a case treated in this manner, in which he obtained a new grow^th 
of bone to fill in the hiatus. 

3. Operative procedures on the bone are not often indicated. The 
ramus of the jaw is never operated on for fixation. The condyle and 
coronoid fractures have been discussed. The two surgical methods 
of jaw fixation are plating and wiring. The operations are performed 
through a small skin incision just below the curve of the cheek. The 
muscle fibers are split rather than cut, and the fractured ends are 
bared enough to permit hole drilling. One or two wires are fastened 
through to hold the fragments, or, if a plate is used, it is frequently 
appliefl on the under side of the jaw as far from the mouth as possible. 
A small two-screw plate is used. Formerly wires were twisted together 
and turned down against the bone, the external incision being closed 
tightly. Recently when I have done the operation of wiring I have 
left the wire ends long, twisted them up firmly to secure apposition, 
and let them protrude from the incision, which was not sutured at 

1 Internat. Congress, 1904, ii. 183. 

2 Ann. of SuFK., 190.5, p. 1. 

3 Western Dental .Jour., 1891, p- 63.5. 



234 



FRACTURES OF THE BONES OF THE FACE 



all. Free drainage follows from the wound from the start, and when 
infeetion sets in it is mild and drains along the wires. As a result, 
bone union is prompt. The wires are pulled out after three weeks, and 
the wound gradually closes with slight discharge for two weeks more. 
I find that these cases leave no permanent bone infection, and the 
patient appreciates the necessity for drainage. 




Fig. 74. — Kingsley's splint. (Stimson.) 



The objection to wiring and plating operation is that perfect apposi- 
tion is not secured and that there is always infection with an ugly 
scar when abscesses form. These are valid objections, and open opera- 
tion is seldom performed except in multiple fractures or those double 




Fig. 75. — Kingsley's splint applied. (Stimson.) 



cases near the angle which cannot be satisfactorily held when the 
body is fractured farther forward. I have never seen a wiring or plat- 
ing operation of the jaw which did not necessitate the removal of the 
foreign material. Plating, I believe, is never called for. Wiring with 
constant drainage is less objectionable. 



FRACTURES AND DISLOCATIOXS OF INFERIOR MAXILLA 235 

The type of splint or dressing depends on the site of fracture and 
the surgeon's famiharity with the method. An oral surgeon or dentist 




Fig. 76. — Matas's splint for fracture of lower jaw. 




Fig. 77. — Matas's splint. 



236 



FRACTURES OF THE BONES OF THE FACE 



should cooperate in every ease. The spHnt which fulfills the require- 
ments of the largest number of fractures is the interdental splint of 
rubber or metal which is moulded and made to fit the individual case 
(Fig. 78). In fracture through or near the symphysis, when the teeth 
are sound, a cap splint cemented on allows the patient to open the 
mouth and to masticate. In the molar region the same type of splint 
can be used, if the teeth are in good condition. If they are not, the 
two jaws are wired together for a couple of weeks, and a cap splint 
can then be applied until bony union is firm. Back of the teeth, 
fracture through the angle and ramus are held by interdental splints, 
wiring, or Angle's bars, and surgical operative procedures are used 
in obstinate deformities, especially in double fractures. 




Fig. 78. — Reduction of fracture of the mandible held by an interdental splint. 



DISLOCATIONS OF THE LOWER JAW. 

Dislocation of the lower jaw, according to Wullstein, represents 1.5 
per cent, of all dislocations. In the 775 dislocations collected at the 
Cook County Hospital there were eight involving this bone. Only 
a proportion of these dislocations are hospital cases, as they seek pro- 
fessional aid at the nearest point to relieve the urgent symptoms. 
The largest number of cases occur in women in midlife; they are 
almost unknown in infants and are rare in adolescence and old age. 
Luxation is commonly forward. It may be backward or outward, 
accompanied by fracture of the skull or the mandible itself. Bilateral 
dislocation forward is more frequent than unilateral. 

Dislocation Forward.— This injury is caused by muscular action in 
yawning and laughing. Direct violence alone or in connection with 



DISLOCATIOXS OF THE LOWER JAW 237 

muscular action may also cause luxation. A slight force depressing 
the lower jaw of a wide-open mouth is sufficient to cause forward 
dislocation. The pulling of a toothy attempts to take large bites, or 
sudden jars of the head, are the usual causes. The temporomaxillary 
joint is co^'ered by a capsule which is reinforced by two heavier lateral 
bands or ligaments and a strong stylomaxillary ligament extending 
from the styloid process of the skull to the ramus of the mandible. 
When the mouth is opened, the interarticular fibrocartilage which 
covers the condyle slides forward, leaving the surface of the glenoid 
cavity and advancing on to the eminentia articularis. If the joint 
capsule is very lax or there is a tear on its anterior surface, it is an 
easy matter for the muscles to pull the mandible farther forward and 
dislocate it. This displacement is aided by leverage action, the 
external pterygoid and temporal muscles furnishing the power to pull 
the bone forward, the fulcrum being supplied by the untorn posterior 
part of the capsule and the stylomaxillary ligament. 

Pathology. — A very few dislocated temporomaxillary joints have 
been examined by dissection, because they are reduced and operation 
is not often indicated. The difficulty of reduction is explained by the 
changed lines of muscle and ligamentous pull after the luxation has 
occurred. The condyle is drawn forward up on to the beginning of 
the zygoma, but that impingement alone is not sufficient to obstruct 
reduction, as removal of the condyle may leave an unreduced joint. 
Rarely the interarticular cartilage may have been torn loose from the 
condyle and fill up the glenoid cavity, so that the mandible cannot be 
forced back into it. Stimson records a case of this kind cured by 
operation.^ The action of the inelastic ligaments which remain untorn 
and the spasm of the stretched muscles of mastication act together 
to pre\'ent the cond^'le from slipping back. 

Sjnnptoms and Diagnosis. — The mouth is held open, the lower jaw 
is held rigidly. When questioned, the patient can indicate that he 
felt the jerk of dislocation. The mouth cannot be closed in most 
cases, or if it is, the teeth of the lower jaw project forward beyond 
those of the upper and there is great pain in the joint. The patient 
cannot move the lower jaw; so chewing is impossible, and talking is 
very indistinct, and there is drooling. Pain is variable; sometimes 
it arises merely from the discomfort of the locked open position of the 
mouth; in other cases there is sharp pain at the joint, increased by 
the spastic muscular contractions. A hollow can be both felt and seen 
in front of the auditory meatus. The muscles attached to the jaw are 
tense, and there is an abnormal prominence below the zygoma. Eff'orts 
to close the mouth are painful, and although the surgeon may be able 
to open the mouth a little wider by pressing down on the chin, resist- 
ance against reduction is firm. 

Luxation of only one of the temporomaxillary joints gives a modifi- 
cation of these symi)toms. The jaw is displaced laterally, the chin 

1 Fractures and Di-slocation, Seventh Edition, p. .548. 



238 FRACTURES OF THE BONES OF THE FACE 

being directed toward the sound side, the mouth is not so widely 
opened, and the Hps may be brought together. The facial asymmetry 
may not be striking, but the deformity within the mouth is visible 
at once. 

Fracture of the jaw is differentiated by the presence of bleeding 
within the mouth and a disturbance of dental alignment. Fracture 
of the condyle may be difficult to differentiate; usually the deformity 
in fracture is loose and easily replaced, to recur immediately when 
support is removed. There is also crepitus and the condyle cannot 
be felt when the jaw is moved. 

Prognosis. — The prognosis is good both in regard to reduction and 
function. Very few cases are irreducible, and the return of function 
is prompt. When the jaw is once dislocated, the possibility of recur- 
rence is great, and habitual dislocation quickly develops. Ahrens^ 
has recorded a rare complication and unusual instance of dislocation 
of the jaw\ The patient was a seven-months-old nursling which was 
threatened with inanition from an acquired habitual luxation of the 
jaw. When first seen the dislocation was of fourteen days' duration. 
The child could not swallow well, as on its attempts to open the mouth 
in order to take the nipple its jaw luxated. The deformity was typical 
and easily reduced, but it recurred quickly, especially as the child 
cried loudly with hunger. This is the youngest case on record that I 
know of, and the cause was obscure. The first dislocation may have 
occurred from crying or from attempts to clean the mouth with swabs. 
Cure was effected by the giving of urethan to induce a long sleep 
with the mouth closed. After the awakening only one breast feeding 
was allowed in the next twenty-four hours, and the dislocation did not 
recur. Probably a laxness of the capsule was the only pathology 
present. 

Treatment. — Manipulation is based on the retention of leverage 
power in the intact ligaments. The ligaments must be relaxed. The 
attendant accomplishes relaxation by pushing down on the chin to 
open the mouth a little farther, then by direct firm pressure on the 
teeth inside the mouth or the mandible on the outside, pushes the jaw 
gently down and back until it slips into place with a jerk. This pro- 
cedure enables the bone to reenter the joint in the way of exit and is 
simple and gentle. A second method which is similar to that of direct 
traction in larger joints is performed by direct pressure downward 
and backward on the molar teeth by the surgeon's thumbs, while 
his hands grasp the jaw and raise the chin simultaneously. The 
pressure overcomes the resistance of the muscles and ligaments and 
forces the condyle back into position. For the practice of this method 
the thumbs of the operator must be well protected by being wrapped 
with a bandage or by a doubly-folded towel placed about them. The 
jaw jerks into place with much force, and unprotected skin always 
suffers between the teeth. As the reduction takes place, the thumb 

1 Monatschr. f. Kinderheilkunde, Berlin, xiii, No. 5, p. 230. 



DISLOCATIONS OF THE LOWER JAW 239 

can be withdrawn laterally into the cheek cavities and so removed 
from the mouth. Unilateral cases need the same type of treatment, 
with more attention to lateral swinging of the jaw toward the affected 
joint as reduction takes place. Rarely a general anesthetic must be 
given to produce relaxation; then the same method of reduction is 
piu-sued. Spontaneous reduction occurs, especially in habitual dis- 
location, and some persons can dislocate the jaw forward and reduce 
it at will by muscular action. 

After-treatment consists in eating of soft food for a few days so that 
chewing will be unnecessary. The patient is cautioned not to laugh or 
yawn and is advised to open the mouth but little. If there is tendency 
to easy recmrence, the jaw can be held for a week in a four-tailed or 
Barton bandage used in jaw fractures. 

Operative treatment is applied to unreduced cases and to fresh 
cases which cannot be slipped into place even with the help of anes- 
thesia. Several attempts at reduction should be made in bilateral 
luxation before operation is decided on. 

Operative approach is made through a skin incision below the 
zygoma, the dissection being carried down to the mandible by splitting 
and retraction. The edge of the parotid gland is held back out of the 
way, and branches of the facial nerve are avoided. If the case has 
been of long standing or a fracture of the condyle has complicated 
it, ^Murphy's method of approach by means of a two-inch incision 
starting on the level of the zygoma and half an inch in front of and on 
a line with the external auditory meatus can be used.^ This opening 
runs upward into the hairy scalp. It has the advantage of opening a 
field from which a flap of temporal fascia may be secured to swing into 
the joint, if the surgeon considers an arthroplasty necessary to avoid 
subsequent ankylosis. The scar is also partly covered by hair. 

After exposure the reduction may be accomplished by leverage with 
a small periosteotome, or if the condyle is an insurmountable difficulty 
to reduction, it can be resected. 

In 1899 McGraw described his operative method of reduction of 
long-standing dislocation. ^ His patient was a man thirty-three years 
old, who had suffered an apoplectic attack and fallen down. The 
lower jaw was dislocated forward, and the true condition was not 
recognized until five months afterward. iVttempts to force reduction 
under anesthesia failed, and McGraw had made a steel hook which 
had space between the prongs and shaft just wide enough to permit 
passage over the jaw at the sigmoid fossa. A small incision, not an 
inch long, affords sufficient room to pass this hook over the bone 
through the split masseter muscle. Traction is made backward and 
downward on the condyles and an assistant pulls up on the chin. 
McGraw used the hook on one side, making traction for fifteen min- 
utes, at the end of which he felt that the jaw was giving a little. The 
other side was opened and the reduction was accomplished by the 

» Clinics, ii, G63. 2 Med. Record, 1899, Ivi. 511. 



240 FRACTURES OF THE BONES OF THE FACE 

hook traction. Immediately after reduction it was noted that the 
teeth still protruded slightly and that there was some prominence 
over the joint, but this displacement slowly subsided, and the jaw 
became normal in function and appearance after a few weeks. Com- 
plete immobilization for two weeks is necessary after operation. 
Other operated cases have been recorded by Brockway.^ His case 
was of thirteen months' standing, and the condyles were pried into 
position through an incision. Dawbarn^ cited two cases in both of 
which reduction was effected by partly dividing the masse ter muscle. 
Mazzoni^^ successfully operated on a case which had remained irredu- 
cible for eight days. Both condyles were resected. 

The after-treatment consists in the holding of the jaw in place for 
at least two weeks by a bandage or a light plaster-of-Paris dressing 
about the head, the patient subsisting on soft diet and not attempting 
to move the jaw. When arthroplasty is performed in connection with 
reduction, it is better to dress the mouth open by means of a wooden 
plug inserted between the teeth. This is worn for at least a month 
until the periarticular structures have become firm and the interposing 
flap between the joint surfaces has had an opportunity to take on new 
function. 

Recurrent Forward Dislocation. — ^Recurrentiorward dislocation may 
become very frequent, although the patient learns to be constantly 
on his guard against it and is able to reduce it himself. To effect a 
cure the attendant should try long immobilization; at least six weeks 
in a head bandage is necessary. If that fails, periarticular injections 
of iodine or alcohol may be used. The final recourse is open operation. 
If the interarticular cartilage is loosened, it may be stitched in place 
or removed entirely, this procedure followed by a capsulorrhaphy to 
tighten the relaxed anterior ligament. 

Recurrent forward subluxation is a condition much like that of the 
snapping or trigger joint. In the act of masticating or talking the 
patient is conscious of the jaw slipping partly out of place, accompanied 
by a cracking noise heard loudly in the ear on the affected side. There 
may be a sensation of partial locking open of the jaw, which is momen- 
tary, and reduction is spontaneous. Rarely the patient has to take 
hold of the jaw, swing it a little laterally, and press it back into posi- 
tion. The condition is usually painless and may depend on a lax cap- 
sule or a loose interarticular cartilage. If repeated unpleasant recur- 
rences make the condition unbearable, the injection treatment can 
be applied. Operation is seldom indicated. 

Dislocation Backward. — Dislocation of the lower jaw backward is 
rare and is nearly always caused by direct violence of a blow on the 
chin. It may be unilateral or double, and two forms of displacement 
exist. In the first the jaw is displaced backward and held by the inter- 
position of the displaced interarticular cartilage. The mouth is closed 

' Johns Hopkins Hosp. Bull., May, 1890. 

2 New York Med. Jour, March 12, 1892. 

3 Gazz. Med. di Roma, 1877, No. 4. 



DTSLOCAriOXS OF THE LOWER JAW 241 

tightly, the lower teeth failing to occlude with the upper. Reduction 
is easily accomplished by traction. The second type involves severe 
direct violence and may be accompanied by fractures of the condyle. 
The anterior wall of the external auditory canal is crushed in, and the 
mouth hangs open in a fixed position. The condyle is driven back- 
ward, and its prominence in the cheek is lost. There may be a bulging 
or a complete occlusion of the auditory canal and bleeding from the 
ear. 

^liiller^ has reported a case of backward dislocation of the temporo- 
maxillary joints with rupture of the bony auditory canals. The 
patient, a man twenty-two years old, fell off his horse, striking his 
face on the ground. There was hemorrhage from both ears, a deep 
cut in the lower lip and unconsciousness. He was unable to occlude 
the teeth, became deaf and could not talk. An irreducible bilateral 
ankylosis of the temporomaxillary joints was established. After a 
few months he suffered an attack of la grippe and was nearly asphyx- 
iated by mucus which he could not expectorate. When he appeared 
for treatment he had a stupid look, his face was immovable and inex- 
pressive; there was retraction of the lower part of the face and the 
labial folds and he talked as if he had a bulbar paralysis. The lower 
teeth were 10 mm. behind the upper and only 8 mm. of motion could 
be obtained when efforts were made to pry the jaws open. Into the 
canal of the left ear a speculum entered only 1 cm., and the anterior 
wall was found pushed against the posterior. Slight movements of 
the jaw were communicated to the anterior wall. In the right ear the 
same findings were present except that the canal admitted a fine 
probe. 

Treatment was applied by means of Rochet's operation.^ An 
incision was made beginning at the lobule of the ear along the posterior 
angle of the mandible. The masseter muscle and periosteum were 
reflected, a triangular piece was removed from the ramus after cutting 
it off from the body by a Gigli saw and a flap of soft parts was inserted 
between the bone ends. Miiller operated on both sides, with an inter- 
val of ten days between operations. Five months later there was 
good motion in the jaw, the masseter had become reeducated, but the 
lower teeth were still retracted so that the patient could not use the 
incisors and canines. 

A case of double congenital ankylosis in a five-year-old child was 
reported by Huguier, who also used Rochet's operation by a trapezoidal 
osteotomy and interposition of a flap of muscle. The best results 
that one can hope to obtain in bilateral ankylosis is a movement of 
lowering and raising the jaw. Lateral movements of propulsion and 
circumduction are gone forever because at the point of bone resection 
the insertion of the external pterygoid muscles are cut ofl'. In a unilat- 
eral ankylosis one might look for a perfect result by the method of 
resection of the condyle or osteotomy of the ascending ramus, because 

1 Paris Chir., 1911, iii, 832. 

- VIII Congress, franc, de chir., 1894 and 1896; Arch, provinc. de Chir. 
16 



242 FRACTURES OF THE BONES OF THE FACE 

one external pterygoid muscle is enough to give propulsion and lateral 
movements to the jaw. 

Upward Dislocation.— Upward dislocation is extremely rare and is 
caused by direct violence on the chin which drives the jaw upward 
through the glenoid cavity of the skull. The condition is similar to 
the central dislocation of the femoral head into the pelvis through the 
shattered acetabulum. The skull fracture constitutes the real injury, 
the displaced position of the jaw is unilateral, and the dangers and 
complications are those of skull fracture and damage of the cranial 
contents. Hemorrhage and brain abscess have been recorded. The 
mouth is fixed slightly open, swallowing and mastication are painful, 
and the ear on the affected side may bleed. Reduction is performed by 
traction downward on the jaw. 

Inward and Outward Dislocation. — ^Inward and outward disloca- 
tions are also rare. Inward dislocation cannot take place without 
fracture of some part of the jaw and possibly of the skull bones about 
the temporomaxillary joint. Outward dislocation occurs under con- 
ditions of fracture and direct violence. The condyle is swung out over 
the zygoma while the coronoid process hooks under the zygomatic 
arch. Reduction is by traction and direct pressure downward on the 
jaw fragment to unhook the condyle, which is then pressed back into 
place. The fracture must then be treated. 



CHAPTER X. 
FRACTURES AND DISLOCATIONS OF THE VERTEBRAE. 

The thirty-three vertebrae composing the spinal cohimn consist of 
the true or movable vertebrae, and the false, or fixed vertebrae formed 
by union of segments in the sacrum and coccyx. Fracture is of greater 
interest in the true vertebrae on account of their more exposed position 
and the fact that the nervous tissues which they guard are of greater 
importance. The normal curves of the spinal column, the cervical, 
convex forward extending to the second thoracic vertebrae; the 
thoracic, concave forward from this point to the twelfth dorsal; .and 
the lumbar, convex anteriorly from the last dorsal to the sacro vertebral 
articulation, furnish a pleasing variation in contour, permit greater 
freedom of action in spinal, head, and limb movements and add to 
the strength and ability to withstand shocks. There is usually present 
a lateral curvature to the right, probably caused by increased muscular 
use of that side in right-handed persons. 

The posterior surface of the column is formed by a line of spinous 
processes which appear subcutaneously and are of interest clinically 
as landmarks, and which are the palpable portions of the vertebral 
column. Palpation of the pharyngeal wall through the mouth permits 
examination of the anterior surfaces of the bodies of the first GiVe 
cervical vertebrae. 

The cervical spines, with the exception of the long seventh cervical, 
are short and bifid at their extremities and are placed horizontally. 
The thoracic spines in the upper part are directed obliquely downward, 
near the midthoracic region they become nearly vertical, and the 
lower thoracic and lumbar spines approach the horizontal again. 
Rarely a spinous process deviates from the customary position in the 
median line and may offer confusing findings in cases of suspected 
spinal fracture. 

The column is elastic because it is composed of so many points 
bound together by the complexity of ligaments, and because of the 
close interlocking of the individual vertebrae and the presence of 
the shock-absorbing intervertebral cartilages in each joint. Further 
safety is provided for the bony column by the curves described, which 
break it up into three separate columns, each one of which demands 
greater force to prorhice })en(ling than a longer curve of equal breadth 
and material. Bending, therefore, under ordinary circumstances, 
must occur before breaking. Position, function to support the trunk 
and head, and the many movements to which it is subjected expose 
the column to mechanical injuries in spite of its construction and 



244 FRACTURES AND DISLOCATIONS OF THE VERTEBRM 

muscular protection. Sprains, caused by exaggeration of any normal 
movements, with laceration of the ligaments are not severe, because 
violence of sufficient force to tear the ligaments widely would rather 
cause fracture or dislocation. For this reason fractures and dis- 
locations of the vertebrse very frequently accompany each other, and 
their pathology is closely intermingled, so that fracture-dislocation 
might be a better general term to apply. 

Direct or indirect violence and, rarely, muscular action, are the 
cause of fractures of the spinal column, and although the injury is of 
importance in its bearing on the supporting function of the head and 
trunk, the injury of the nervous content is of more interest. Fractures 
caused by indirect violence, or an exaggeration of the normal curves, 
are more common. In this type the arches are separated and the 
bodies are compressed, while in fractures arising from direct violence 
the reverse is true. In both the medullary canal is the least likely to 
be subjected to violence. Displacement is nearly always that of the 
upper fragment driven forward on the lower when indirect violence is 
the cause, so that the cord is compressed between the arch of the upper 
and the body of the lower vertebra. 

Occurrence. — In the collection of 11,302 fractures at the Cook County 
Hospital the vertebrse were broken in 138 instances, or 1.2 per cent. 
Corwin's collection of 11,035 fractures at the Minnequa Hospital gave 
242 spine fractures, this high proportion arising from the fact that 
most of the patients were miners, a class exposed to this type of injury. 
Stimson's statistics gave 0.5 per cent, of the total number as fractures 
of the vertebrae. Cervical fractures are the most common, dorsal 
fractures coming next, and lumbar last in order. Of the 138 fractures 
mentioned above, 47 were specified as cervical. In 1914 at the Cook 
County Hospital there were 11 fractures of the vertebrae, 6 of which 
were cervical, 2 of the 4th, 1 of the 5th, 2 of the 6th, and 1 
of the 7th. There were two 1st lumbar fractures, both of which recov- 
ered. Cervical cases have a much higher mortality than any others; 
1 of the 6 above lived three months. Of these 11 cases, 8 died, 
3 recovered; 4 laminectomies were done, all with fatal results. Two 
or more vertebrae may be broken simultaneously, especially in the 
cervical region, rarely in the lumbar (see Figs. 79 and 80). Children 
because of more elastic spines, and the aged, who are not exposed to 
severe injuries, rarely have these fractures, and most of them occur in 
male adults, teamsters, structural workers, miners, etc. 

Fractures of the spinous and transverse processes are now found to 
be more frequent than was formerly believed, because of more careful 
study of spinal injuries by means of the Roentgen rays. The body of 
the vertebra is most frequently concerned, particularly in the dorsal 
and lumbar regions. 

Pathology. — Fracture of the vertebral body may be a crack across 
it in any direction completely through its width, or a fissure ending in 

1 Jour. Am. Med. Assn., Ivii, 1351. 



FRACTURES AND DISLOCATIONS OF THE VERTEBRA 245 

the cancellous tissue. The vertebrae, like the os calcis, are built for 
weight-bearing and shock absorption and are made up of cancellous 




i 



Fig. 79. — Fracture of the spinous processes of the third and sixth cervical. 

bone with a narrow cortical shell. If a fissured fracture is complete, 
the line may run obliquely from above downward and forward, or 
vertically, or even horizontally, with no displacement or separation 
of fragments. A split-off wedge may be displaced forward, a usual 




Fig. 80. — Crushing of the third and fourth cervical bodies with fracture of their spinous 

processes. 



condition fFigs. 81, 82, and 83), or the body may be crushed or com- 
minuted into several })ieces. The transverse and oblique fractures 



'240 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

occur in the upper part of the body, and the upper fragment is dis- 
placed forward and downward with the portion of the spine above, 




Fig. 81. — Split-off wedge from the body of the lower thoracic vertebra with an oblique 

plane of separation. 

the lower part remaining in its normal position in connection with 
the bodies below. This causes an angulation in the bony spine with 
a sharp point projecting backward like a gibbus, the external deform- 
ity being enhanced by the separation of the spinous process of the 




Fig. 82. — Crushing fracture of the body of the lumbar vertebra. 



broken vertebra and the intact one above it. Lateral rotation or 
simple lateral displacement may be a complication (Fig. 84). A narrow 



FRACTURES AXD DISLOCATIONS OP THE VERTEBRA 247 

range of rotation can be present without additional bony injury, 
especially if the fracture of the body is transverse. INIore extensive 




Fig. 83. — Fracture of the body of the sixth cervical with forward displacement of a 

fragment. 

rotation or distinct lateral angulation can only be accomplished by 
accompanying fracture or dislocation of the articular processes. 




Fig. 84. — Fracture of the bodies and arches at the junction of the cervical and dorsal 
regions. There was some rotary displacement but no cord symptoms. (Dr. C. B. 
Davis.) 



These conditions all result in change and diminution in size of the 
medullarv canal. The canal mav be narrowed so much that the cord 



24§ FRACTVkES AHD DISLOCATIONJ^ OP THE VERTEBRA 

is compressed or even severed by the edge of the body below and the 
arches above, or in rotation or lateral displacement the canal may be 
narrowed in a lateral diameter so that similar cord compression results. 




Fig. 85. — Compression fracture of the lumbar body of nineteen years' standing, cord 
symptoms first appearing at that time. (Potter.) 

Compression of one or more vertebral bodies from violence, especially 
in a slightly flexed position, causes crushing of the cancellous bone and 




Fig. 86. — Fracture dislocation of the lower cervical region. 

it becomes denser. This may effect the whole body, or the upper and 
lower anterior edges, so that the normal quadrilateral appearance in 
roentgenogram profile becomes wedge-shaped. This is very evident 



FRACTURES AXD DISLOCATIOXS OF THE VERTEBRA 249 

in old compression fractures which may have existed for years without 
cord symptoms or changes, the bone wearing down until the injured 
body is triangular in outline (see Fig. 85). 

Although the bodies are constructed to bear these sudden applica- 
tions of force, the posterior portions of the vertebrae are so firmly 
locked and fastened by the ligaments that in flexed positions they 
maintain their slightly elastic support and the bodies are forced to 
give by compression. The cancellous tissue may be forced out laterally 
or backward into the medullary canal, and the intervertebral cartilages 
may come to lie in contact. Impaction of one part of the body into 
another, as in the extremities of long bones, or the femoral neck, may 
also cause this body compression. The intervertebral cartilage may 




Fig. 87. — Fracture dislocation of cervical region. Note the forward displacement of 
the bodies of the upper vertebrae. 



be. forced out, instead of the bone being crushed, and they may 
pull out with them shells or splinters of bone. Associated injuries, 
fractures of the transverse processes of the vertebrse or fissures in 
neighboring bodies are found. 

Later changes consisting of callus formation and extrusion at the 
intervertebral foramina or into the medullary canal may cause press- 
ure s\Tnptoms and signs through change in the angulation of the 
cord or the decrease in the foramina! aperture, and demand treatment 
for relief of pain and paralyses. 

The arches of the vertebrae are broken in connection with fracture 
of other parts, rarely alone, except in gunshots (Figs. S8 and 89). The 
most frequently involved region is the cervical, because the individual 
vertebrje are broad anrl are lacking in strong supporting spinous and 



250 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

transverse processes. This complication is not present in more than 10 
per cent, of dorsal and lumbar fractures. Loosened pieces, broken off 




Fig. 88. — Fracture of the arch of cervical vertebra. 




Fig. 89. — Fracture of arch of cervical vertebra with multiple separation of the ribs at 
their vertebral attachments. 



by direct violence, may be driven into the medullary cavity and cause 
a severance of the cord and death. A spinal injury with bladder and 



FRACTVRES AXD DISLOCATIONS OF THE VERTEBRAE 251 

rectal paralysis arising from splinter of bone driven into the cord is 
recorded by Borchard.^ 

Fractnres of the trcnib'vcr^e and articular 'praccf^i^c^ occur under 
two' conditions. In the upper portion of the spine they usually are 
found in conjunction with fracture or dislocation of other parts of 
the vertebra^. In the lower spine, especially the lumbar region, they 
are caused frequently by muscular action (see Fig. 90). Fractures of 
the ribs close to the spine in the dorsal region msiy involve the articula- 
tion with the transverse processes and vice versa. Dislocations of the 
cervical vertebra often are the cause of fractures of the articular pro- 
cess, but if this process is first fractured, dislocation may easily follow. 




Fig. 90. — Fracture of the transverse process of the second lumbar vertebra by muscular 

action. 

Hoffman^ reported an instance of fracture of five of the transverse 
processes of the lumbar region following muscular exertion. He 
-tates that there are 9 cases on record, the 1st and 2d lumbar pro- 
cesses fractured in four instances, the 3d in six, and the 4th and 5th 
in two. The case illustrated in Fig. 91 has not been reported before 
and shows the widest separation of fragments of any case on record. 
These fractures are caused by forcible contraction of the psoas and 
quadratus lumborum and longissimus dorsi muscles. That the pro- 
ces.ses do not fracture more frequently is because severe traction 
strains are nearly always met in an upright position, in which the 
strain is sustained by the broadest diameter of the process. Fracture 



' Archiv f. Klin. Chir., cv, No. 2. 

2 Med. Klin., Berlin, August, 1011, x, No. .32. 



252 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

occurs (luring the lifting of heavy weights, when the individual is in 
a flexed forward position. A case in a fifty-year-old man was reported 
by Lange.^ He strained his back lifting a heavy tray of samples out 
of a trunk and experienced great pain when stooping over, walking 
fast, or riding on cars. There was a spot of acute tenderness about 
the size of a dollar just to the left of the last lumbar vertebra, and 
although the patient was well developed and used to lifting feats, 
the pain persisted and resisted all treatment. Roentgenogram betrayed 




Fig. 91. — Multiple fractures of the transverse processes of the lumbar vertebrae with wide 
separation of fragments. These cases are frequently diagnosed as sprained backs. 

a fracture of the left transverse process of the 5th lumbar (Fig. 92), 
tilted up at an angle as though drawn there by muscle (erector spinse) 
and some union to the vertebra seemed present. 

A second case in a thirty-five-year-old man followed a severe blow 
on the back by an automobile crank handle. There was right lumbar 
rigidit}' and pain, the Roentgen picture showing an upward displace- 
ment of the transverse process of the 1st lumbar and no other injury. 



New York Med. Jour., October, 1906, p. 691. 



FRACTURES AXD DISLOCATIOXS OF THE VERTEBRAE 



:od 



Ehrlich^ reported 1 case^ and Hoglund'- reported 7 cases met with in six 
years, all verified by roentgenogram. Diagnosis is of importance in 
these cases from the prognostic standpoint of injuries called sprained 
backs. 

An early symptom is abdominal pain caused by the pressure of 
fragments or of the hematoma on the nerve trunks. This may also 
cause reflex rigidity of the abdominal wall, or the pressure or stretch- 
ing of the psoas may cause pain simulating appendicitis. Tauton^ 
reported a diagnostic sign of localized pain arising from lifting of the 




llG. 



92. — Fracture of transverse process on opposite sides of the lumbar vertebrae. 
There is also a fragment of bone broken off the iliac crest. 



leg when the patient is lying on the back. Other symptoms are local 
tenderness in the lateral lumbar region on pressure and painful bend- 
ing. These may either all subside or else lead to constant pain and a 
neurotic condition, the relief of which can only be reached by excision 
of the fragments. Many of these cases have undoubtedly been called 
lumbago, osteo-arthritis, traumatic neuroses, or railroad spine, before 
the use of the Roentgen rays. 



' Deutsch. Ztschr. f. Chir., xcii, 413. 
' Rev. de Chir., xlii. 1101. 



2 Ibid., cxvi, 321. 



254 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

Fracture of the spinous processes constitutes more than one-half 
of the fractures of the cervical vertebrae according to Scudder. Direct 
violence to the spines is the most frequent cause and is in many 
instances followed or accompanied by hyperflexion with one or the 
other end of the spine fixed, the opposite one mobile. The jackknife 
mechanism caused by men on wagons driving under a bridge or door- 
way, is frequently the cause (see Fig. 93). Muscular action as in sud- 
den hyperflexion sometimes accompanied by rotation also is a cause. 
In the dorsal region fracture of the transverse process or other part of 
the ver ebra frequently accompanies. The broken spine may be 
displaced downward or laterally and downward, the soft parts in most 
cases giving little evidence of the trauma. Scott^ reports a case 
caused by the trauma of an iron pipe thirty inches long, falling from 
a height onto a man's back. Some of these injuries are open frac- 
tures, most of them closed. Unless the loose spine can be grasped 
and moved, or crepitus obtained, diagnosis is difficult and depends on 
a good lateral roentgenogram. In the stronger lower dorsal and lum- 




FiG. 93. — The jackknife mechanism of spinal fracture seen when teamsters try to drive 
under a doorway not high enough to allow passage. Adapted from Cotton. 

bar vertebrae, the site of fracture may be near the tip of the process; 
in the dorsal and cervical regions the line is generally nearer the mass 
of the vertebra. 

Cord hemorrhage after spinal injury, may be extradural or intra- 
dural as in the skull. The cord is hung in the spinal column in its 
watery bed of cerebrospinal fluid with ample space around it. Extra- 
dural hemorrhage from the plexus of veins may spread quickly and 
widely up and down the canal, but I believe is rarely responsible for 
pressure symptoms. There may be a temporary increase in intraspinal 
and intracranial pressure, but severe hemorrhage without fracture, 
or without actual injury of the cord itself is rare, although the con- 
dition of cord contusion or concussion, like that affecting the brain, 
is accepted. The rapid circulation and absorption of the spinal fluid 
precludes great pressure from hemorrhage. Rarely hemorrhage is 
very free, and spinal puncture will bring forth almost pure blood. 

Intradural hemorrhage or hematomyelia is more serious and is 



Railway Surg. Jour., 1915, p. 180. 



FRACTURES AXD DISLOCATIONS OF THE VERTEBRA 255 

probably caused by a stretching of the cord m hyperflexion, or exten- 
sion, or from direct violence following bone injury. This hemorrhage 
is usually found in the cervical and upper dorsal regions, in the gray 
matter, spreading upward and downward for many segments and 
may be accompanied by capillary hemorrhages in the white matter. 
Anatomically the reader must recall that the motor or anterior nerve 
roots arise from the anterior horn of the cord, and are the axones of 
ganglionic cells in that horn. These connect above or within the 
central nervous system, with the cortex, and below, or externally, 
with the muscles in the periphery. The medullary sheath is supplied 
to the axone as it passes out from the anterior cord; the neurilemma 
is not supplied, however, until the axone leaves the spinal fissure. 

The posterior or sensory nerve roots are composed of efferent axones 
arising in the ganglionic cells of the posterior root ganglia, which are 
located for the most part within the intervertebral foramina. Axones 
also extend from these ganglionic cells to the periphery and the sen- 
sory neurone is made up of afferent axones, to the periphery, and 
efferent axones, to the cord, together with the ganglionic cell bodies. 
These sensory axones, except that portion passing within the spinal 
cord, have a neurilemma. Neurilemmatous axones, if united under 
favorable conditions after division, are capable of regeneration; that 
is, the spinal nerves and the cauda equina will unite, but the cord 
does not. (See cases of supposed regeneration of cord to follow.) 

Scar tissue fills in after destruction of the cord, but this is func- 
tionless. Nash^ reported a case of spinal fracture with paraplegia 
below the lumbar region. The spinal canal, exposed eight months 
later, between the 8th and 11th dorsal vertebrae, revealed only fibrous 
strands following complete disappearance of the cord. Taylor^ cites 
a case of a female trapeze performer who fell and fractured the 6th 
cervical segment. Immediate laminectomy was done, but she died 
in three days, and the subsequent examination of the cord showed a 
widely extending, tubular hemorrhage down the cord substance. 
He believed that the operation helped toward the fatal result, because 
it added to the shock, which is greater in the cervical region than in 
decompression of the brain, on account of the proximity of the medulla. 
The extravasation of blood in the cord may be so great that temporary 
hemiplegia results, clearing up later either completely or in part. 
The extravasated blood in causing distention may also cause so much 
pressure that neighboring axis-cylinders are completely destroyed and 
are replaced by granulation and cicatricial tissue, a cyst or cavity 
remaining, which contains the modified serum. If the surrounding 
nerve elements are not destroyed, but are merely under such pressure 
that function is suspended, it is important to diagnose the condition 
and operate to relieve the tension. The hematomyelia may aft'ect 
one side of the cord alone. Such a case was reported by Tilney and 



' Australas. Med. Gaz., xxxv, 314. 

2 Boston Med. and Surg. Jour., clxvii, No. 20, 075. 



256 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

Nichols/ following fracture of the 6th cervical in a diving accident. 
The man (twenty-eight years old) had an immediate hemiplegia of 
the right arm and leg with awkwardness of movements on the left 
side and no loss of consciousness. There were no permanent eye, 
bladder, or rectal symptoms, and the final condition was a flaccid 
paralysis of the right upper extremity, spastic paralysis of the right 
lower extremity, increase of the right tendon reflexes and loss of the 
right abdominal epigastric and cremasteric reflexes. There was also 
a positive Babinsky and ankle-clonus on the right side. The whole 
left side was normal. 

Some years ago at the Cook County Hospital there was a patient 
who had been slugged in an alley and rendered unconscious. After 
a short time he awoke and managed to drag himself home, a distance 
of two squares. He never had a complete paralysis of the limbs and 
after two weeks began to walk. In a few months he gradually devel- 
oped a weakness and disassociation in the limbs and an anesthesia 
to heat and pain, a typical syringomyelia. A Roentgen picture, taken 
six months after the accident, showed a fracture of the 7th cervical 
vertebra. He had probably had a central hematomyelia. One might 
be tempted to conclude that in similar fractures or spinal injury, if 
the pain and heat senses are disturbed early, if ever so slightly, there 
is indication of central hematomyelia with distention of the central 
canal, and the probability of operation would be very carefully weighed. 
On the other hand, if the tactile sense was involved as well as the pain 
and temperature sense, one would feel sure that the hemorrhage was 
not confined solely to the central canal, but involved the cord more 
extensively, or the disturbance was possibly caused by pressure from 
without, and operation for clot or bone pressure would be indicated. 
Allen, on a basis somewhat similar to this, advocated early operation 
with a delicate longitudinal opening in the dura to relieve cord press- 
ure within by drainage. (See Treatment.) Frazier^ records a case 
treated by this method. There was a mid-dorsal fracture which was 
opened within five hours from the time of injury, a gush of fluid appear- 
ing when the contused site was cut into. After four months there was 
some return of sensation, none of muscular control. On the whole, 
results are disappointing; on account of the character of these injuries, 
one surgeon rarely has an extensive experience in them and cannot 
adopt a well-planned line of treatment. A few months ago I had a 
fatal case of fracture of the 7th cervical vertebra. No operation was 
performed. At the autopsy the cord was carefully removed. It must 
be understood that in removing the spinal cord it should not be cut 
into or pressed upon, nor can it be bent or flexed. Any of these con- 
ditions will cause changes which are apparent in a microscopic section 
and lead to false deductions pathologically. The cord in question 
showed practically no gross change on the dural surface. Delicate 

1 New York Neurol. Soc, October 6, 1914, abstracted Jour. Am. Med. Assn., 
November 28, 1914. 

2 Surg., Gynec. and Obst., March, 1913. 



FRACTURES AXD DISLOCATIONS OF THE VERTEBRA 257 

palpation by the index finger run along its continuity disclosed an 
area of depression or softening at a site which corresponded to the 
bone fracture level. When the dura and pia were opened there was 
found a hemorrhagic mass beneath, which extended two or three 
segments downward and one upward. Section of this cord verified 
this hemorrhage and destruction (see Figs. 94, 95, and 96). Undoubt- 
edly whatever damage is done to the nervous elements of the cord is 
done immediately at the time of injury, and no line of treatment will 
affect the permanent destruction. Pressure from bone, or fluid from 





Fig. 94 



Fig. 95 




Fig. 96 

Figs. 94, 95, and 96. — Schematic drawings made from sections of the spinal cord in 

fatal case of fracture of the 6th cervical vertebra. At the lesion site the removed 

[cord showed no evidence of injury, a palpable depression was found there by the finger. 

'ig. 94 shows hemorrhage in the central canal above the cord compression. Figs. 95 

id 96 are in the upper and lower dorsal regions, showing the downward extent of the 

lemorrhage. 



lemorrhage or edema, is amenable to treatment. Cases which are 
[seen weeks or months after injury with nerve root or cord symptoms 

)f pain and paresis, present pathology based on displacement of the 

lord caused by callus formation, or a wearing down of a broken body 
[until the cord ultimately comes within pressure limits. Cysts of 

)Iood .serum may also cause late pressure effects. In these cases the 
[axis-cylinders have not been destroyed in the injury, and relief can 
be promised through removal of bone or cyst pressure to allow a 
[resumption of normal function by the nervous elements. 
17 



258 FRACTURES AND DISLOCATIONS OF THE VERTEBRAE 



Symptoms and Diagnosis. — Symptoms of fracture of the vertebrae 
may be entirely lacking, or at least unrecognized as coming from the 
spine. The evidence common to gross lesions, involving the bony 
parts and the cord also, are those of paralysis and loss of sensation 
of all parts below the segment supplied by nerves which take origin 
in the injured area. It is therefore necessary to have general knowl- 
edge of the points in the cord at which each nerve originates, and 
the fact must be borne in mind that many spinal nerves originate at 
a point higher in the cord than their emergence from the bony column. 




Fig. 97.- 



-Emergence and peripheral distribution of spinal cord segments. (Adapted from 
Scudder.) 



From their point of origin these nerves pass downward within the 
vertebral canal for some distance; the anatomical finding is that the 
lower the nerve's origin, the longer its course within the column (see 
Fig. 97). For practical use the cord may be divided into four parts 
to aid the memory: (1) Between the occiput and the spine of the 6th 
cervical vertebra the 8th cervical nerves take their origin in the 
cord. (2) Between the 6th cervical spine and the 10th dorsal spine 
arise the twelve dorsal nerves. (3) At the level of the 11th and 12th 
dorsal spines the five lumbar nerves originate and (4) the five sacral 
nerves arise at the cord level corresponding to the 1st lumbar spine. 



i 



FRACTURES ^IXD DISLOCATIOXS OF THE VERTEBRA 259 

General symptoms found in fractures elsewhere in the body are 
recognized in the spine after trauma. There is shock of varying degree, 
pain and tenderness to manipulation over the site of injury, crepitus 
in some instances which may be felt by the patient when he is moved, 
and abnormal mobility and deformity in the back. There may also 
be swelling, which masks the deformity of an angular backward dis- 
placement, like a kyphotic gibbus. If dislocation or lateral displace- 
ment is present, the deformity is more irregular in appearance and may 
not be noticeable in any degree. A case admitted to the Cook County 
Hospital with a rather high, remittent fever and great prostration 
was considered a walking typhoid. After several days, when being 
given a bath, the patient was rolled over in bed, and death followed 
in a few minutes. Autopsy showed fracture of the 4th cervical ver- 
tebra; the sudden movement had caused fatal cord pressure. There 
had been no external spine deformity. A similar fatal case has been 
mentioned by Pickard.^ His patient injured his arm and also had 
some pain in the neck which was supposedly due to a wrench. After 
the arm was dressed the patient sat up in bed asking for a drink, to 
receive which he turned his head and collapsed. 

Trauma resulting in temporary separation of vertebrae with imme- 
diate reposition, may cause hemorrhage from the venous plexus 
surrounding the cord and produce paralysis from pressure. Rough 
handling by those who do not appreciate the gravity of the injury, 
or by overzealous assistants in ambulance and hospital service, may 
increase displacements and cause more extensive injury and increased 
paralysis. 

A gradual increase in the extent of the paralysis indicates pressure 
extending from extradural hemorrhage in progress, or from hemato- 
myelia. An ascending myelitis from nutritional or circulatory dis- 
turbance produces similar results. As described in the pathology of 
hematomyelia, the hemorrhage may be unilateral. Usually the first 
symptoms are total paraplegia, although rarely hemiplegia is found. 
If the gray column on one side alone is affected, the nerve cells taking 
origin from that area are destroyed and the condition improves, so 
that in cervical hematomyelia the paralysis of limbs and sphincters 
may be recovered from, and one arm may remain useless. There is 
a loss of heat and pain sensation in the limb, but no loss of tactile 
sense. 

Incomplete transverse crushing or damage of the cord results in 
irregular paraplegia and an irregular loss of pain, heat, and tactile 
sensation, part of which may be regained. The side affected most 
becomes spastic later, with exaggerated tendon reflexes. Complete 
transverse lesion gives complete permanent sensory and motor paraly- 
sis below the lesion. Different observers assert that in early stages 
following spinal injury it is impossible; to say whether the crushing is 
total or not, and indications for operation (which sec) may l)c over- 
lookcfl. 

' Kailwaj- Surg. Jour., 1914, p. HfH. 



2(i() FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

The sensory and motor paralysis extends from the peripheral dis- 
tribution of nerves taking their origin at the level of the lesion. At 
first all reflexes and motion may be lost; later these return and become 
increased with spastic contractions. If the lesion is high enough to 
in\'olve the abdominal muscles and the nervous control of the bladder 
and rectum, there is retention of urine and feces with abdominal dis- 
tention. This is caused not so much by lack of sphincter control as 
it is by loss of muscular tone in the bladder and bowel walls. If the 
catheter is not used, the bladder distends until a point of overflow is 
reached, and the urine begins to dribble away from an incontinence 
of retention. The bowels may follow the same course, usually at a 
much later period. These distended bladders are much like those in 
the terminal stages of a chronic prostatic hypertrophy, inasmuch 
as they are lacking in muscular tone, and catheterization to relieve 
distention will not restore this tone, and an infection which rapidly 
spreads up the urinary tract surely follows. Temporary suppression 
of urine may be due to the abolition of reflexes after concussion of the 
cord, and sphincteric and muscular control may return. Hematuria 
from simultaneous kidney injury has been observed. 

Respiratory symptoms in high lesions concern the muscular action 
of the chest and abdominal muscles, or the diaphragm. Breathing 
may be continued by the diaphragm from the phrenic innervation 
when the chest muscles are paralyzed. Hypostatic congestion and 
pneumonia are frequent sequelae. Pressure sores over the sacrum, 
trochanter, or buttocks appear very early. If the patient is not kept 
clean and dry, or is allowed to lie in one position too long, these may 
be evident within eighteen to twenty-four hours as red spots the size 
of the palm. Within a few days the skin sloughs, and a crater-like 
ulcer appears which is extremely difficult to control and may hasten 
death from septic absorption. 

Priapism is found in nearly half the cases of cervical or upper dorsal 
fractures and practically never in lesions below the 1st lumbar. This 
is not a true erection, but rather a uniform, flaccid turgescence of the 
penis, which is not bothersome and generally becomes relaxed within 
a week or ten days, especially if urinary incontinence is well estab- 
lished. Ejaculations are r£i,re. In many cases of hanging, with frac- 
ture of the upper cervical vertebrae, ejaculations are found after the 
body is cut down. 

The evidence furnished by roentgenograms is of the greatest value 
in determining indications for treatment and the presence of bone 
fragments pressing on the cord. It should be obtained immediately, 
when possible, with the avoidance of all jars and movements of the 
spine which might exaggerate the existing conditions. Stereoscopic 
pictures are the best. Lumbar puncture, well below the site of lesion 
in most cases, which should be done with all aseptic precautions, is 
also an aid in diagnosis. If the spinal fluid is under increased tension, 
it demonstrates that there may be contusion or edema of the cord, 
or possibly hematomyelia when it is clear. If blood-stained, the 



FRACTURES OF THE CERVICAL VERTEBRAE 



261 



presence of blood in the dural sac is proved; and if the fluid is nearly 
all blood, alarming hemorrhage may be robbed of its pressure effects 
by operative interference. As in skull injuries, the spinal puncture 
may have a therapeutic effect of value. 



FRACTURES OF THE CERVICAL VERTEBRA. 

The most important are the injuries of the atlas and axis because 
of their proximity to the medulla oblongata and their position above 
the roots of the phrenic and other nerves governing respiration. Frac- 
ture dislocations often occur together, although either one or the 
other may occur alone (Fig. 98). Partial subluxation laterally is the 




Fro. 98. — Lateral view of fracture of the axis near the base of the odontoid process. 



most frequent injury of the atlas. Fracture of the odontoid process with 
lateral dislocation of the atlas are the next most commonly reported. 
Injuries of the atlas alone are rare. 

Sjnnptoms. — The symptoms depend on the displacement, and if 
there is none, life may be spared, but most cases die at once. Slight 
as\Tnmetrical positions of the head, accompanied by neck stiffness 
and occipital neuralgia, with muscular rigidity and resistance to all 
motion, are the usual findings. Death follows later in cases with 
small displacement or in fracture of the odontoid process, when a 
sudden change in position causes the head to slip forward and crush 
or compress the cord. A secondary myelitis from the primary injury, 
the abnormal position or callus pressure pursuing a long course, may 
ultimately cause death from involvement of the medulla. SHght 



2()2 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

displaceineiits are considered common by Walton.^ The physical 
signs as given by Mixter and Osgood^ are: inspection reveals some 
unnsual displacement on account of the asymmetrical position of the 
head. By palpation, the full line of spinous processes and their rela- 
tive anteroposterior position is determined, and if the spine of the 
axis is abnormally prominent, a fracture of the odontoid is probable. 
In a normal neck the transverse process of the atlas can be palpated 
about half-way between the angle of the jaw and the mastoid. If 
there is rotatory displacement there will be two abnormal prominences, 
first from the forward displacement of the dislocated mass of the atlas 
and the other on the opposite side of the neck, lower down, which is 
the portion of the axis made more prominent by the slipping back of 
the atlas. The finger examining in the mouth may feel displacement 
along the pharyngeal wall. 

In the unilateral type, the displacement is rotatory; the atlas slips 
forward on the side which gives way and either impinges on the articu- 
lar process below or rests in the intervertebral notch. This does not 
cause cord compression or death, and these lesions can be reduced by 
manipulation after long standing. The mechanism of these subluxa- 
tions is probably that given by Corner.^ Free movements of the head 
demand that the ligaments at the occiput and spine shall be loose so 
that the head is held by muscular action alone. If it chances that the 
supporting muscular action is absent, any blow received on the neck 
has a ''flying start" to produce dislocation or its complicating fracture. 
The integrity of the odontoid process is the most important point to 
determine from the standpoint of prognosis and treatment. This can 
be ascertained by a roentgenogram taken through the open mouth 
if the position of the head permits. In Corner's collection of 20 cases 
the odontoid was broken in 6 out of 8 instances which were fatal and 
in only 1 out of 10 which survived. But 2 of the fatal cases followed 
the accident immediately; some survived many years. 

Van Assen"^ collected 19 cases of injury to the atlas, most of which 
were associated with other vertebrae, and 12 cases of injury to the 
axis, 9 of which were fractures of the odontoid process. Other cases 
of fracture of the odontoid have since been reported by Kiliani,^ one 
of the tip of the process; by Wilson,^ one in which final displacement 
was caused by an osteopath; and by Lambotte, one in which the 
patient, a woman, caused the condition by a sudden movement of 
her head while sewing, with death a year later. Elliott and Sachs' 
reported a case in a fifty-year-old man who fell when eighteen years 
of age, landing on the back of his neck. He was in bed for six months. 
For one year he could not move his head, and many years later, after 
being struck on the shoulder, he developed some weakness but worked 

1 Boston Med. and Surg. Jour., 1903. 

2 Ann. Surg., li, 193; and Am. Jour. Orthop. Surg., 1910. 

3 Ann. of Surg., 1907. '• Ztschr. f. orthop. Chir., xxi. 
6 Ann. of Surg., lix, 297. 

6 Ibid., April, 1907. - ' Ibid., Ivi, 876. 



i 



FRACTURES OF THE CERVICAL VERTEBRA 



263 



for five months. Sudden weakness and loss of sensation in both hands 
and the right leg then developed. From this he recovered by resting, 
and in subsequent years, following other falls, he had urinary incon- 
tinence and paralysis from which he recovered. Finallv after a fall 




Fig. 99. — Photograph of Ryerson'.s case of cervical .subluxation. (Kindness of 

Dr. Ryerson.) 

on the ice he developed paraplegia, urinary and fecal incontinence, 
and weakness in the arms. A roentgenogram showed fracture of the 
odontoid, not in its neck, but deeply down through the extreme upper 
part of the body of the vertebra. The study of the specimen demon- 
strated that the atlas and odontoid process had been carried forward 



264 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

evenly and not rotated and that attrition had caused the formation 
of a false joint, the axis minus its odontoid having been pushed back- 
ward and worn down. There was a bony ankylosis of the odontoid 
process to the arch of the atlas, and that portion of the spine, without 
the check ligaments, was very insecure. This was a good illustration 
of the result of the mechanism by "flying start," by giving the blow^ 
on the back of the head or neck which expends much of its force on 




Fig. 100.- 



-Photograph of Ryerson's case of cervical subluxation. 
Dr. Ryerson.) 



(Kindness of 



the odontoid. This man has lived for thirty-two years with inter- 
mittent paralysis, his cervical spinal cord segment being balanced 
all the time on the borderline of safety. 

Two cases of subluxation of the atlas were reported by Ely.^ The 
first, a boy aged thirteen years, had rheumatism preceding a fall on the 
ice, which he concealed, and a stiff neck went undiagnosed. The Second 



Ann. of Surg., liv, 20. 



41 



FRACTURES OF THE CERVICAL VERTEBRA 



265 



case followed a fall down an elevator shaft with an asymmetrical head 
position and irregular sensory and motor paralysis. Pilcher^ reported 
a case which was under observation for ten years. The man fell, strik- 
ing his forehead, and had a paraplegia, and four months later open 
operation was done. No fracture was seen, but the atlas was dis- 




FiG. 101. 



-Photograph of Ryerson's case of cervical subluxation. (Kindness of 
Dr. Ryerson.) 



located forward on the axis, and the condition could not be corrected. 
Nine years later he could walk, but one arm remained paralyzed. 
Examination after that time showed the head rotated to the left, and 



Ann. of Surg., li, 208. 



200 FRACTVRES AND DISLOCATIONS OF THE VERTEBRA 

a bony callus uniting the atlas and axis could both be felt and demon- 
strated by the Roentgen rays.^ 

The cervical subluxations are characterized by a fixed position of 
the neck with great rigidity of the muscles. Torticollis is differentiated 
by the fact that the sternocleidomastoids are not more concerned 
than other muscles. Satisfactory and quick diagnosis is aided by the 
roentgenogram. 

An exhaustive study of the subluxations of the atlas upon the axis 
has been made by Ogilvy,^ based on the study of 46 reports on the 




Fig. 102. — Roentgenogram of Ryerson's case of spinal subluxation. 

subject. He added his own case in a fourteen-year-old boy who sus- 
tained a bilateral flexion subluxation forward of the atlas, w^hile pitch- 
ing a baseball. Attempts to reduce this by manipulation failed, but 
his condition improved, and Ogilvy considered that fear of a sudden 



1 Eisendrath, Ann. of Surg., xlii, 245; Bogardus, Inter. Jour, of Surg., xxiv, No. 2; 
Thomas, Med. and Surg. Reports, Boston City Hosp., 1900, 11th series; Walton, Boston 
Med. and Surg. Jour., 1903. 

2 Am. Jour. Orthop. Surg., 1914, p. 314. 



FRACTURES OF THE CERVICAL VERTEBRAE 



26: 



increase in the amount of displacement, with danger of death, grew 
less as time passed. He advises early reduction if the patient is seen 




Fig. 103. — A case of fraeturo of the axis in a woman diagnosed originally as neiiriti 
of the occipital nerve. Roentgenogram made through the open mouth. 




Fig. 104. — The author's case of fracture of the axis. The odontoid was uninjured. 
The patient had tried to work for three weeks after falling four feet onto his neck and 
came to the hospital finally because of occipital pain. Roentgenogram through the open 
mouth. 

shortly after the accident, and later treatment in cases with distress- 
ing .symptoms. 



268 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

Griffith^ reported 3 eases of partial luxation of the atlas on the 
axis. Total dislocations of the spine in the neck are very rare and 





Fig. 105 Fig. 106 

Figs. 105 and 106.— Position in which the patient with fracture of the axis, shown in the 
preceding figure, held his head. 




Fig. 107 Fig. 108 

Figs. 107 and 108. — Head cast used for cervical vertebrae fractures. 

concern usually the 3d to the 6th cervical. Meyer's^ case was of the 
4th cervical forward, reduction being made under scopalamine-mor- 

1 Am. .Jour. Orthop. Surg., 1914, p. 332. 

2 Deut. Ztschr. f. Chir., Leipzig, cxxix. 



FRACTURES OF THE CERVICAL VERTEBRAE 



269 



pliine anesthesia. ]Many are combined with fracture, but a few have 
not been so connected. Earher cases were reported by Steinmann/ 
among which Avas the first one confirmed by Roentgen rays. RiedP 
and Derby/ the accident to whose case occurred during sleep, have 
reported cases. ]\Ialkitz^ collected 9 cases, 4 accompanied by fracture, 
and Quetsch^ 3 cases without fracture. 

Treatment of Cervical Fracture-dislocations. — Simple unilateral rota- 
tory displacement can very often be reduced by manipulation. This 
consists in the operator's first freeing the dislocated articular process 
by lifting the head and then rotating it into place with dorso- 
lateral flexion. As a guide to manipulation it is recalled that the chin 
always points to the side opposite the main lesion. If reduction is 
accomplished and there is doubt of the fracture of the odontoid, a 




Fig. 100 



Fig. 110 



Figs. 109 and 110. — Views of patient at time he left hospital. There is little deformity 

and no pain. 

Thomas or Calot plaster collar or a plaster helmet should be worn 
for many months. Ryerson^ reported a successful reduction by man- 
ipulation of a subluxation of the 3d cervical vertebra of six months' 
chiration (Figs. 99, 100, 101, and 102). It is also possible to aid 
refluction by digital pressure in the pharynx. The subsequent immob- 
ihzation should be long; fatal results have followed early removal of 
the protection. Less severe displacement can be treated by chin straps 
and head harness, with a ten-pound extension weight over the head 



1 Arch. f. klin. Chir.. lOOG, Bd. Ixxviii. 

2 Wiener klin. Wchnschr., 1907, No. 2. 
' Bristol Med. Jour., .July 23. 1910. 

* Arch. f. Orthop., Mechan. u. Unfalls Chir., Bd. ii. Heft 4. 
5 Miinch. med. Wchschr., 1912, No. 18. 
« Am. Jour. Orthop. Surg., Feljruary, 1910. 



270 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

of the bed, which is elevated to give counter-extension from the body 
sHpping down (Figs. 103 to 110). 

Operative treatment, as devised by Mixter and Osgood, is indicated 
when there is much pain and reduction cannot be made permanently. 
A four-inch incision is made over the suboccipital spines, the hooked 
spine of the axis is identified, and the forwardly displaced posterior 
arch of the atlas is exposed. A strong suture of braided silk soaked in 
compound tincture of benzoin is passed through the arch, avoiding the 
spinal cord. Pressure on the anterior arch is made by the finger in 
the pharynx, and traction is made by the ligature on the posterior 
arch until reduction is accomplished. This is held and the atlas is 
anchored by a fastening of the silk ligature around the spine of the 
axis. A prepared leather cuirass or plaster-of-Paris dressing is applied 
and left on for at least two months. 



FRACTURE-DISLOCATIONS OF THE CERVICAL AND FIRST TWO 
DORSAL VERTEBRA. 

This division, excluding the atlas and axis, is indicated because of 
the source of the brachial plexus from the last four cervical and first 
dorsal pairs of nerves and the origin of the phrenic at the level of the 
third and fourth cervical vertebrse. In the lower cervicodorsal region 
the symptoms are variable; the resulting paralyses involve the arms 
and chest, but the motor and sensory findings may differ widely. 
Extension of the paralytic process, which at first may have involved 
the trunk no higher than the umbilicus, is common, the first thirty- 
six hours after accident determining the limit to which it will go. 
Hyperesthesia in the arms accompanied by sharp burning pains or 
nerve pressure, is often present and is a most distressing symptom 
because manipulations, or contact against the arm, increase the trouble. 
Muscle spasm is also found. If there are irritative pains in the arms 
with no absolute paralysis above the abdomen, the process will prob- 
ably extend to the arm and may be partial. When the sixth cervical 
is fractured or dislocated on the seventh with cord damage, the intrin- 
sic muscles of the hand are paralyzed, and the arms seek a position of 
rest, lying on the chest. When the fifth cervical segment is involved, 
the arm is usually abducted, the forearm fiexed, and the whole 
extremity rotated outward. There is loss of sensation of the whole 
arm except at the shoulder. 

Lesions of the midcervical region may involve the phrenic by direct 
damage or the extension of a hematomyelia. 

When the accessory chest muscles of respiration are involved, the 
diaphragm carries on the act, pushing the abdominal muscles out at 
each respiration. No strong expulsive efforts can be made to clear 
the bronchi or throat of mucus, and rales quickly appear in the chest. 
This mucus stasis and a recumbent position lead to early death in 
most cases. The extension of hematomyelia may cause involvement 



DISLOCATIOXS OF CERVICAL AXD DORSAL VERTEBRA 271 

of the phrenic within a few hours, the respiration and pulse falUng to 
a low rate before death. 

Physical examination may detect no deformity, crepitus, or local 
tenderness. Pressure along the spine may increase the local pain, or 
an abnormal mobility can be detected. The subjective sense of crepi- 
tus is also possible, although the examiner may not be able to feel it. 
Neck and head position vary. The head may be in a normal position, 
with tense cervical muscles which aim to protect against painful or 
dangerous movement. The head may also assume a rigid position 
of flexion and rotation as described under the atlas and axis injuries. 
Spellissy^ reported a dislocation of the sixth cervical vertebra by the 
jackknife mechanism. The man's temperature rose from 94° to 103° 
in sixteen hours; death ensued in twenty hours. The gross pathology 
was a rupture of the common posterior spinal ligament, a stripping of 
the anterior ligament from the vertebral bodies, and a complete pos- 
terior dislocation of the sixth and upper cervical vertebrae in one 
mass. The cervical cord was nearly completely severed, and the free 
hemorrhage found between the divided ends extended down to the 
level of the fifth thoracic. 

Some observers have also reported instances of self-reducing dis- 
locations of the cervical spine without fracture. Grossly and by roent- 
genogram, there is no evidence of fracture, but paralyses may be 
present. Autopsy findings show no bone lesions, but the cord shows 
evidence of pressure opposite the intervertebral cartilages, as if it had 
been compressed between two dislocated vertebrae which had imme- 
diately resumed their normal position. 

I have notes on a fracture of the transverse process of the seventh 
cervical vertebra with paralysis of the eighth cervical and first dorsal 
nerves much like a lower arm type of brachial plexus paralysis (exact 
reference mislaid). Open operation revealed a small loose fragment 
of bone which was depressing the root of the eighth cervical nerve. 
Removal was followed by relief from the cramps and by other im- 
provement. 

Three months before ^^Titing this I operated on a case of fracture 
of the fifth and sixth cervical vertebrae involving the laminse and 
spines. There was paraplegia and complete paralysis of one arm, the 
other arm being but partially affected. Laminectomy of the fifth 
and sixth cervical xertebrae was done, and the dura was apparently 
intact. The cord bulged out into the opening made in the bony cover- 
ing, and the dura was gently slit open for drainage. There has since 
been complete recovery of motion in one arm and one leg; the other 
arm still shows a paralysis of the flexors of the hand and fingers, but 
the extensors of the wrist are functionating. If no further improve- 
ment develops, a tendoplasty will be performed to utilize one of the 
active extensors through the grafting of it into the flexor group. The 
other leg is spastic but the patient can walk with a cane (see Figs. 
Ill and 112). 

' Ann. of Surg., xlvii, Vi7. 



272 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 




Fig. 111.- 



-Lateral view, showing the amount of flexion of the head after operation. 
Note the scar visible on the left side of the neck. 




Fig. 112. 



-Postoperative scar after laminectomy of fifth and sixth cervical, 
well the head is held up and the incision lateral of the midline. 



Note how 



Diagnosis is difficult even with the aid of the Roentgen rays. It is 
also difficult to hold the sensitized plate at a low enough level to 
obtain good views of the lower cervical vertebrae, on account of the 
interference of the neck and shoulder tissues. Suspected injuries in 
the cervical region, with or without paralyses, must be carefully 
immobilized, if operation is not indicated or refused. Many cases are 
quickly fatal, over one-third dying within the first w^eek, many within 
the first forty-eight hours. A few instances of prolongation of life 
for months have been recorded. 



FRACTURE-DISLOCATIONS OF THE DORSAL REGION. 

Symptoms. — S^Tnptoms of fracture of the dorsal vertebrae below 
the first two are more striking than those of the cervical vertebrae, 
and diagnosis is easier. The nerves in the dorsal region have a simpler 
method of exit from the spine, and the level of injury is easier to map 
out, both from the nerve symptoms and the external examination. 
]\Iost of these fractures involve the body of the vertebrae, and there is 
apparent deformity arising from their crushed condition. The hiatus 
between the spines of the injured vertebra and the one below can in 
many instances be palpated by deep pressure. Here also the motor 
and sensory paralysis may vary, especially in the lower dorsal region, 
the sensory disturbances failing at first to reach the height of the rnotor. 
Patellar reflexes are generally lost, plantar reflexes vary, and the 
bladder and rectum are usually involved. If there is recovery, a spastic 
paralysis of the legs follows, and contractions may also be found. If 
the lumbar enlargement of the cord is injured, there are irritative 
pain s\Tnptoms in the legs. Hematomyelia also occurs in this area. 
The immediate prognosis is better than in cervical injuries; the remote 
causes of death, such as urinary tract infections and myelitis, depend 
on the involvement of the bladder and the use of the catheter. 

The tenth to the twelfth dorsal are the most frequent site of injury. 
Sprain fracture, by muscular action, is more frequent in the dorsal 
region. This involves the spinous process, which is displaced down- 
ward, and non-union generally results. Gurlt^ found 21 cases of com- 
plete pseudarthrosis of spinal fractures, 4 involving the spinous pro- 
cesses. Skillern^ reported 1 of the first dorsal. The loose pieces 
should be excised, if there are any symptoms. 

Dislocations in the dorsal region are more commonly between the 
twelfth dorsal and the first lumbar, although the inferior articular 
processes do not favor luxation, because they look forward and out- 
ward like the lumbar vertebrae. The displacements may be to either 
side by rotation or directly forward and backward. These may 
accompany fracture, but simple forward dislocation is possible by a 
flexion of the spine which raises the inferior articular processes of 

» Handbuch, 18G2. 2 Ann. of Surg., June, 1913, p. 908. 

18 



274 FRACTURES AND DISLOCATIONS OF THE VERTEBRJE 

the upper vertebra above and away from the superior processes 
of the lower vertebra. 

Bihiteral, forward and backward dislocations are those usually 
found. Bilateral in opposite directions are rare; lateral alone very 
rare and are caused by a combination of extreme flexion of the trunk 
and direct violence at the point of greatest bending on the side or 
back. Such a mechanism is offered by crushing injuries under a heavy 
falling body or blows from moving cars, etc. 

Symptoms and diagnosis are much the same as in fractures, and the 
absence of crepitus does not prove that fracture is absent. If the 
deformity can be reduced and has no tendency to recur, dislocation 
is probable. The prognosis is like' that of fracture; the higher up, the 
less favorable, and the greater the pathology of cord injury, the less 
favorable. 

Treatment. — ^Treatment is applied by extension of the shoulders 
with the hips fixed or counter-extended on the Hawley table, and after- 
treatment is like that of fracture, a long rest in bed or a plaster jacket 
(Fig. 113). 




Fig. 113. — Bradford frame with adjustment for tightening the canvas. Slits are cut 
and tied back so that the patient can. be easily handled. 



FRACTURE-DISLOCATIONS OF THE LUMBAR VERTEBR-ffi. 

Symptoms. — The cord ends at the lower level of the first lumbar, so 
that injuries at or below this point involve the cauda equina. Frac- 
tures and dislocations are rare. Borchard^ reported a case of success- 
ful reduction and complete cure of forward dislocation of the first 
lumbar. The symptoms cover bladder and rectal retention, loss of 
patellar and plantar reflexes if the lesion is complete, and partial or 
total paralysis of the legs. Because the cauda is composed of separated 
nerve bundles, many may escape damage, and the lesions are partial 
with irregular findings of motor paralyses up to the level of the bone 
injury. Spastic gait and contractures may follow. Considerable 
deformity may be present with no nerve symptoms. In Borchard's 
case there were severe nerve pressure symptoms with paralysis. An 
open operation was done, and the first lumbar vertebra was pulled 
back into place and wired, the roentgenogram showing complete 
reduction. 

J Arch. f. klin. Chir,, Berlin, cv, No. 2. 



FRACTURE-DISLOCATIONS OF THE DORSAL REGION 2/o 

Prognosis. — The prognosis is much better than in cervical and dorsal 
injuries but is on the whole poor. ]Many recoveries have been recorded, 
but if there is not complete replacement or release of pressure on the 
Cauda, permanent paralyses result in restricted activity. The bone 
lesion may heal with a deformity or a weakness in support which 
precludes much function of the back. Walking with bent or crooked 
position often results; a few cases obtain excellent function in spite 
of deformity. On account of the regeneration of the neurilemmatous 
nerve in the cauda, these injuries which involve it offer special 
inducements for operation. AYhen the progress of the case ceases, 
or if no spontaneous attempt at recovery is found, the spine should 
be opened and pressiu'e removed or nerves sutured, to meet the con- 
ditions present. No arbitrary time for this operation can be set; 
improvements have followed nerve suture after many months. As 
a rule, however, under favorable conditions, the attempt should be 
made within six or eight weeks after the accident. 

Dislocations of the lumbar vertebrae are uncommon. Most injuries 
are a combination of fracture and dislocation not only of the lumbar 
region but of neighboring vertebrae. Severe crushing injuries which 
involve the soft parts and the abdominal viscera are concomitants. 
The ligaments are torn, and the intervertebral cartilage may be dis- 
integrated and chips of bone pulled off the edge of the bodies. Spinous 
processes and ribs may also be broken. The mechanism is probably 
in a majority of instances a hyperflexion. The lumbar vertebrae are 
protected by the strong and heavy lumbar muscles and the interlock- 
ing of the articular processes, as described under Fracture. The bodies 
of the vertebrae are also heavy and are protected from jars and strains 
by the thick intervertebral cartilages, which give elasticity. Antero- 
posterior flexion may cause a pure dislocation, but it is almost impos- 
sible for lateral flexion to cause movement out of place unless the 
transverse processes are broken. 

The s\TQptoms and prognosis are about the same as in lumbar 
fractures, the paralysis usually being of partial character on account 
of the division of the cauda equina into isolated bundles. There is 
local deformity, pain and tenderness, and walking disability. 

Treatment. — Anterior dislocations are probably best reduced by 
open operation, as in Borchard's case. Manipulation, traction on 
the shoulders, and forward pressure on the lower part of the displaced 
-pine, might cause reduction. Backward displacements have been 
replaced by pressure on the deformity portion aided by extension or 
counter-extension in the long axis of the spine. As in other areas, if 
there are no nerve involvements, and manii)ulations fail to correct the 
deformity, it may be ignored and allowecl to heal firmly in a plaster 
jacket worn for four to six months. 

Course and Prognosis. — It is impossible to make general statements 
•^•overin^ these two jK)ints, as they are so inextrica})ly mixed with 
I)athol(jgy and treatment, and those paragra])hs must be read to cover 
the ground. The course of fracture itself involves merely the changes 



270 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

tliat occur in the bone. In simple fracture of a spine or transverse 
process, luiion may occur as in some of the cases cited. This is bony, 
if fragments are in apposition. Rarely an excess of callus is thrown 
out to cause pressure on the nearby nervous structures. Most unions 
are bone; non-union of remotely placed transverse or even spinous 
j^rocesses is common. So few of the cases recover or are followed to 
death for autopsy findings that there is meager information to be had 
on the subject of subsequent bone changes. Gurlt, in his Handbuch, 
records 21 cases of complete pseudarthrosis, 5 of spinous processes, 
3 of transverse processes, and 13 of the arches of the lumbar vertebrse 




Fig. 114. — Old fracture of the second lumbar with rotary displacement. 



and sacrum. Some of these cases have been considered as congenital 
defects, and their sequence to fracture disputed. 

Fractures of the body often lead to absorption of a broken-off frag- 
ment. If several bodies are comminuted, they may all become adherent 
in a mass of bone callus, a gibbus forming, and a rigid spine resulting. 
If a single body has been injured, it tends to wear down and assume 
the shape shown in Fig. 114 after many years. Projecting callus or 
pieces of bone become rounded off unless osteo-arthritic changes occur 
in connection with the same changes in other bones of the body. 
This causes bony overgrowth and lipping projections so commonly 
seen in chronic osteo-arthritis of the spine. Bony union is very slow 
in the vertebrae. Infection and osteomyelitis at the site of the injury 



FRACTURE-DISLOCATIONS OF THE DORSAL REGION 277 

are common, probably on account of the deficient blood supply and 
the size of the bones. 

The damage of the cord is a ^•e^y diti'erent matter, as the pathology 
of the repair shifts to the conditions governing nervous tissues. The 
cord may be completely destroyed and show no evidence on examina- 
tion of its envelope. Crandon found a case in his collection at the 
Boston City Hospital where death occurred one month after fracture 
of the first dorsal with complete degeneration of the cord at that level 
without macroscopic changes in its covering. Reference to the elemen- 
tary anatomical description of the cord in the beginning of this chapter 
leads to a conclusion that a lesion of continuity of the cord may heal 
by scar tissue, or the torn dura may close over in the same way. 
Improvements after severe injury are probably caused by the fact 
that some nervous fibers in the cord escaped destruction and later 
resumed function. This is possible even if the medullary sheath is 
destroyed, because the naked axis-cylinders continue their function. 
If a cord is torn and sutured, anatomical regeneration may occur, 
but functional repair does not. After severe injuries secondary 
degeneration ensues, which is the result of the injury itself and does 
not cause compression symptoms. This degeneration follows injury 
whether the compression is removed at once or not, because these 
highly specialized tissues are quickly destroyed and do not regene- 
rate. 

It is expected, then, that the course of concussion of the cord, where 
there is no anatomical change and the function is suspended, will be 
short and offer an excellent prognosis. Contusions, with or without 
bone lesions, may also be of no consequence. But if the cord matter 
has been destroyed, the result is severe and permanent. The mildest 
change consists in a traumatic zonal inflammation; the nerve fibers 
may be forced apart by blood or transudate with a temporary sus- 
pension of function but no permanent axonal destruction. Effusion 
of blood about the cord is not important; if pressure symptoms are 
caused they usually clear up within a month. 

In hematomyelia, which involves the softer or less resistant gray 
matter, some nerve elements are destroyed, and there is more or less 
pressure on the surrounding area. After absorption of this blood 
anfl the destroyed nerve tissue, a cavity is left, and although partial 
functional recovery has become established there is some permanent 
weakness of the area supplied by the segment. 

Krause^ mentions the reported cases of cords regenerated after 
section. 2 Fowler's case of complete severance after gunshot made 
a partial recovery and obtained some bladder and rectal control and 
could get about on crutches. Fowler waited ten days before opera- 
tion, while the Stewart-Harte case, which made practically a com- 

1 Chir. des Gehirn? u. Rufkenmarks, 1911, Bd. ii, .S12. 

- Stewart and Harte, Philadelphia Med. .Jour., 1902, ix, 23, and Tr. Am. Surg. Assn., 
190.5. U'.i: Fowler, Ann. of Surg., 1905, xlii. No. 4; Shirres, Montreal Med. Jo\ir., 
April, 1905, xxxiv. 



278 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

plete recovery, was operated on within three hours. Arrangements 
have been made for the recovery of this cord when the patient dies. 

Marie^ has found that in his service at the Salpetriere only 5 patients 
out of IS with wounds of the spinal cord had died after six months. 
He showed before the Academic de Medecine 5 patients who had been 
struck by projectiles in the cervical region. All had suffered imme- 
diate and persistent paralyses of all four limbs with sphincter trouble, 
and all had made consistent progressive improvement, so that several 
could walk and run, and all could dress and feed themselves. 

When the lesion has caused bladder and rectal paralysis, the bladder 
distends and an incontinence of retention is soon established. If no 
catheterization is done, there is much less danger of cystitis developing, 
and as the patient is insensible to the distention, the bladder should 
not be relieved in the early days after injury. When cystitis does 
develop, it should be treated in accordance with surgical principles 
governing infections of the tract. Very rarely a bladder may be 
ruptured or its walls may slough from pressure and hasten death. 
Lesions of the upper dorsal and lower cervical regions often end in 
death from pneumonia or hypostatic congestion in a few days. 

Pressure necrosis, sores on the buttocks, thighs or back, do not 
tend to spread rapidly after the first sloughing, if they are given prompt 
attention. In some cases of incomplete lesion they heal and later 
break open again. They may become infected from urine and feces, 
extend quickly, and hasten the end by septic absorption and exhaus- 
tion. The sacrum or femora may be exposed and secondary osteo- 
myelitis and meningitis follow. Marie,^ basing an opinion on experi- 
ences in the war, reported to the Academic de Medecine that he did 
not believe that bed-sores were the result of trophic disturbance, but 
were due to prolonged pressure and the infection from discharges. 
The slightest soiling of the surface must be cared for by washing and 
powdering, and the patient's position should be shifted every two 
hours, night and day. 

Patients with incomplete lesion who survive the fracture injury 
and its immediate consequences, may live for many weeks, the course 
ending with a high, irregular fever. Others live for years, finally suc- 
cumbing to pressure necrosis or kidney infections. Still a smaller 
proportion regain reflexes and motor and sensory power, beginning 
with muscular twitchings, and may become ambulatory with crutches. 

Years after fracture with no cord symptoms, secondary degenera- 
tion may appear. Pachymeningitis and death follow. 

A case of medicolegal interest touching the prognosis of spinal 
injuries was recorded in an abstract in the Journal of the American 
Medical Association.^ This was a damage suit for injury of the spinal 
cord with permanent, crippling which destroyed all earning capacity. 
(Padricks vs. Great Northern Railway Co., Minn., 150, N. W. R. 807.) 

1 Jour. Am. Med. Assn., Ixv, No. 2, p. 183. 

2 Ibid., June 19, 1915, Ixiv, No. 25. 

3 Ibid.. No. 20. p. 1680. 



FRACTURE-DISLOCATIONS OF THE DORSAL REGION 279 

The plaintiff was awarded 135,000, which the court considered exces- 
sive and reduced to $30,000 because one-third of the amount repre- 
sented a simi sufficient to compensate for the lost earning capacity 
and the rest provided for personal attendance and compensation for 
suffering and deprivation of the enjojrment of life. This last factor 
was considered an elastic one, but no money compensation could 
even be adequate for serious permanent personal injuries, and the 
amount of reco^'ery must be limited by courts to protect the various 
interests involved. The plaintiff did not appear bed-ridden, he could 
move about somewhat, and his mind was unimpaired. 

Treatment. — Fractures of the spine demand the same general treat- 
ment given fractures anj^diere in the body, namely, rest and immob- 
ilization after reduction of deformity, if this last is possible. Because 
the bone lesion is of less importance than the cord injury, the first 
thought in treatment should be to preserve the cord from any further 
damage. When an individual sustains an injury to the spine, he 
should not be moved about or rolled over by anyone until the medical 
man is present. He should be kept in the position in which he is 
found, and transportation to the place of treatment should be on a 
flat stretcher in the same position. This requires the most delicate 
handling. We know that fractures of the upper cervical region have 
a high mortality, and there is often no chance for treatment. It is 
also best not to decide treatment on any statistical basis, as the lesions 
of reported cases are so different. 

Depending on the character of the lesion, treatment is (1) expectant 
and palliative; (2) reduction and fixation in a permanent dressing; 
(3) operative, by laminectomy, either primary or secondary. 

1. Expectant treatment is applied to two types: (a) Those cases 
with fractures of process or which have no cord symptoms, and (b) 
cases of undoubted complete transverse lesion, which offer no hope 
for recovery and are moribund. These patients are put to bed and 
made comfortable, and heat is applied and antishock measures adopted. 
If there is severe irritation pain, morphine is used. This treatment 
does not include active means to relieve the bladder, which I believe 
are uncalled for under any circumstances. The catheter should not 
be used ; the bladder is allowed to distend until an incontinence causes 
a dribbling away of the urine, morphine being given to control what 
pain develops. This treatment avoids cystitis, and in the very mild 
lesions a temporary interference with bladder action will later be 
rectified. The patient can be put on a Bradford frame or a water 
bed. In symptomless fractures of the spinous processes a plaster 
jacket is applied. Spinal puncture may relieve pain and intraspinal 
pressure, as suggested under Diagnosis. 

2. Reduction and fixation in a permanent dressing is reserved for 
those cases with a bony deformity without cord injury, and for those 
with cord svTnptoms who refuse open operation. The patient is placed 
on the Hawley or flat table with means for suspension of the back, or 
if the gibbosity is great, he is rolled over, the body being turned as 



280 FRACTURES AND DISLOCATIONS OF THE VERTEBRAE 

a whole, and extension is made on the trunk and legs in opposite 
directions. This extension is made slowly in the line of the column 
axis, and is checked by constant knowledge of changes in the con- 
dition of the cord as shown by reflexes and changes in sensation and 
motion during the slow procedure of reduction. At the slightest sign 
of pressure on the cord, the attempt must cease, and open operation 
performed. When the deformity is straightened out, a plaster jacket 
or corset built up from the iliac crest as in Pott's disease, is applied 
with the body in suspension. Cases of marked deformity are more 
safely treated by open operation and reduction under the eye. Bur- 
rell studied 244 cases of spine fracture treated at the Boston City 
Hospital from 1864 to 1905, and in the time prior to 1887^ he had 
advocated in his treatment the correction and cast plan. In 16 cases 
so treated by immediate rectification and plaster, 3 died, 3 were not 
improved, and 10 were improved. Eliot^ records a case in a thirty- 
four-year-old male with depression of the twelfth dorsal and a pro- 
jection of the spine and a |-inch dislocation in the horizontal plane. 
There were paralyses. The back was stretched and a cast applied, 
and in eight months the patient could walk well. 

For other references see footnote.^ 

3. Operative Treatment. — Primary laminectomy is undoubtedly indi- 
cated in many cases and should be done at once after painstaking 
examination of the patient for decision as to the character of the cord 
lesion. If there is a matked kyphosis which manipulation does not 
affect, even in the absence of cord symptoms, operation is indicated 
for an attempt to straighten out the column, or by laminectomy to 
forestall the chance of compression. Nearly all surgeons who deal 
with these fractures favor the statement that in known complete 
transverse destruction of the cord, operation is useless and may hasten 
death from shock or infection. Though this may be agreed upon as 
basic, it is not so easy to have an agreement on the symptoms which 
prove absolute destruction, and the few cases of suture of the cord 
and recovery after injury or gunshot recorded above would encourage 
the hope that this step should be taken in the seemingly hopeless cases. 

A roentgenogram of the spine should be made to determine the 
position of fragments, displacements, and foreign bodies. If there are 
symptoms of complete transverse lesion, with an irremediable cord, 
do not operate."* ' 

These symptoms are: 

1 . Complete flaccid paralyses below the lesion. 

2. Complete loss of all forms of sensation, anesthesia with sharp 
demarcation. 

1 Med. Com. Massachusetts Med. Soc, 1887, xiv, No. 1. 

2 Ann. of Surg., Hi, 409. 

* Gurlt, Handbuch, collection 270 cases; Thorburn, Manchester, Med. Chron., 1892, 
xvi, 73; Morton, Practitioner, 1901, Ixvii, 307; Lloyd, 227 cases, Philadelphia Med. 
Jour., February 15, 1902; .Jour. Am. Med. Assn., 1901, p. 1014. 

4 Thomas, Boston City Hosp. Med. and Surg. Reports, 1900; Sencert and Auvray, 
Bull, Med., Paris, 1909, p. 909. 



FRACTURE-DISLOCATIOXS OF THE DORSAL REGION 281 

3. Absence of reflexes. 

4. Complete paralysis of bladder and rectum, with t^Tapanites and 
priapism. 

5. Absence of variatioji in s^Tnptoms. 

6. Absence of irritation phenomena, such as pain and twitching. 

7. Vasomotor paralysis, heat and sweating of parts. 

8. Early appearance of reaction of degeneration in muscles. 
Partial Lesions. — ^Nlotor paralysis is not absolute and may be very 

slight. Single groups of muscles alone may be involved. There is 
also a variation in the quality of the paralysis from the flaccid to the 
spastic type, the sensory and vasomotor symptoms are not complete, 
and the bladder and rectal disturbance is also incomplete. In addi- 
tion there is evidence of irritability of the spine with pain, and the 
reflexes gradually show some improvement. 

Allen has done some very instructive experimental work^ in which 
he succeeded in determining the amount of impact which can be 
sustained by the spinal cord of an animal with recovery. He showed 
that a median longitudinal incision into and through the spinal cord 
produces few s^Tnptoms, and succeeded in producing an uneventful 
recovery in dogs whose spinal cord had been subjected to a force of 
h^-perimpact and immediately treated by this operation. Control 
dogs did not recover. The practical conclusion was that fracture 
dislocation of the human spine with existing s\Tnptoms of transverse 
lesion should be subjected to laminectomy at the earliest possible 
moment, and if the cord was not completely severed, it should be 
drained of the products of hemorrhage and edema by a median longi- 
tudinal incision through the dura and cord. 

Laminectomy is a major operation and has its dangers, but many 
of them arise from the critical condition of the patient from the shock 
of the accompanying trauma. Coley^ thinks its dangers are over- 
rated, and Bailey and Elsberg^ consider it a major, but believe the 
burden of the mortality in laminectomy statistics should be borne 
partly by the accompanying disorders. By exclusion of 5 moribund 
cases, they performed 29 primary laminectomies without a death and 
believe that even in the absence of increased pressure within the canal 
or a discoverable lesion, the operation and incision of the dura may be 
of great benefit. A general statement that partial lesions, injuries 
with displaced bone fragments, or dislocations shown by the roent- 
genogram, cases of failure of reduction by manipulation in cervical 
cases, and fracture of the arches with pressure symptoms and caudal 
lesions, should be given early operation by laminectomy, is conser- 
vative, and is subscribed to by such men as Krause,"* Estes,^ Elsberg,^ 

' Jour. Am. Med. Assn., September 9, 1911. 

2 Ann. of Surg., Ivi, 60. 

3 .Jour. Am. Med. Assn., March, 1912, p. 67.5. 
* Lf)(:. rit. 

^ Am. .Jour. Surg., 1910, xxiv, .341. 

'' Ibid., xxviii. No. 1; .39; Internat. Abst. Surg , .Juno, 1914; Ann. of Surg., lviii,'290. 



282 FRACTURES AND DISLOCATIONS OF THE VERTEBRA 

Fnizior/ Bottomlcy,- Allen, McWilliams,^ Taylor/ and Miller. Coriat 
and Crandon^ reported 3 cases of spinal cord injury and believe that 
they demonstrated two important facts; first, the value of an exact 
regional diagnosis of the lesion in the cord, thus limiting the extent 
of the laminectomy, and second, the excellent results which may be 
obtained in spinal cord surgery from early operation. 

When the cord is crushed in one segment, there may be damage at 
a distance from the main lesion by hemorrhage, as described in the 
pathology, so that even if relief of pressure were afforded by local 
laminectomy the distant injury would remain. Consequently after 
operation and removal of laminae the surgeon may not have removed 
all pressure, and he must still be in doubt. For this reason it is often 
best to wait a few days to remove the possibility of contusion of the 
cord, to attempt to establish the permanency of apparent transverse 
lesions. Shock can be overcome in a few hours, and the operation 
does not threaten life and may save some cord axones from destruc- 
tion. Pain, if present, can also frequently be relieved. Those cases 
which are moribund with great bone displacement and a high and 
rising temperature, must not be subjected to operation. Late laminec- 
tomy is advocated because it avoids shock, and if the injury to the 
cord is not irremediable at the time of accident, it is rare for bone or 
other pressure to cause permanent abolition of function. If a partial 
lesion is not operated upon early, it should be opened when there is 
not improvement, or when a retrogression of symptoms is noted. 
The same statement applies to hematomyelia and hematorrachis with 
retrogressive changes caused by the blood-clot or adhesions. If the 
deformity has not been reduced, or excess callus causes symptoms, 
late laminectomy should be done. Thorburn,^ after 7 laminec- 
tomies became pessimistic of their value, Lloyd,^ in a table of 82 
immediate laminectomies and 103 late operations concluded that the 
statistics were decidedly against immediate operation, but that opera- 
tion should be done when shock was past. Other men who favor 
late operation for the reasons mentioned above are Krause, Oliver,^ 
Bottomly, Eliot, Taylor, Miller and DeQuervain, quoted by Powers, 
208 operated cases.^ Early or immediate operation has fallen into 
disrepute largely because the cases were not selected and complete 
transverse lesions and moribund patients were operated on. 

C. E. Black's collection of 552 cases from the literature gave the 
following figures: Of the operated cases 49.2 per cent, recovered; 
of the non-operated cases 25 per cent, recovered and 65 per cent. died. 

Cervical region mortality, operation 71 per cent., without operation 
85 per cent.; dorsal region mortality, operation 48 per cent., without 

1 Surg., Gynec. and Obst., March, 1913. 2 Loc. cit. 

3 Ann. of Surg., xlviii, 140. ^ Loc. cit. 

5 Boston City Hosp. Med. Reports, 16th series, p. 235. 

•■' British Med. Jour., February 15, 1902. 

7 Philadelphia Med. Jour., February 22, 1902, p. 324, 

* Cincinnati Lancet-Clinic, November 7, 1903. 

« Med. Rec, New York, Ixxix, 667. 



FRACTVRE-DISLOCATIOXS OF THE DORSAL REGION 283 

operation, 04 per cent.; lumbar region mortality, operation 2G per 
cent., without operation 50 per cent. 

Gimshot wounds of the spine may cause severe injury without 
penetration of the cord, and they offer special indications for treat- 
ment. Treatment of these injuries or fractures depends partly on the 
direction from which the shot came and the amount of cord and bone 
damage. If from behind, the bullet may enter the cord, penetrate it, 
and become buried in the body of the vertebra or other tissues, with 
little additional harm, other than the destruction of the cord. In 
the last year I have had one case of shot from the rear with fracture 
of a lamina and complete destruction of the cord, and another of shot 
through the chest with complete severance of cord, the bullet lying 
just imder the skin to one side of the spinous process of the eleventh 
dorsal. The injury must be considered from the standpoint of (1) 
injury to the cord; (2) fracture of the bony parts; (3) injury of 
thoracic or abdominal viscera. Puncture of organs may demand 
immediate laparotomy or other operation, or shock may be so great 
that none can be undertaken. The wound tract should be disinfected, 
and after shock is past the spine can be opened to relieve pressure 
from clots or bone and to permit drainage and minimize chances of 
infection. 

Suspension of function may be caused by contusion or by a pulping 
of the nervous structures without damage to the dura. Pilcher^ 
recorded a case which involved the fifth and sixth cervical, but which 
gave no symptoms after one month. A case which concerned the 
seventh to tenth dorsal was opened by Winslow.^ There was no 
penetration of the cord, but there was complete destruction of it, as 
was also found true of a second case at autopsy. Coley^ successfully 
removed a bullet from between the first and second dorsals in a patient 
who gave symptoms of complete laceration of the cord. There were 
two pieces of bullet imbedded in the substance, and the final result 
was full restoration of all function. A similar case was reported by 
Fort, in the discussion of Winslow's paper, in which complete recovery 
followed a gunshot which drove a spicule of the transverse process 
into the cord with symptoms of a complete transverse lesion. 

Early operation is favored in gunshots in accordance with Allen's 
experiments and practical results furnished by clinical cases. Prewitt,'* 
after seeing 58 cases of spinal wounds in the Spanish-American war, 
concluded that where the region is accessible and the patient's condi- 
tion justifies, it was best to operate. Of these cases 33 were fatal; 
of 25 operated on 12 recovered. Krajeroski-^ reviewed 32 cases of 
laminectomy in the literature without removal of the bullet, with 24 
deaths. Schmidf^ shows from the German government statistics that 

1 Ann. of Surg., xxxviii, 812. 

' Tr. Southern Surg, and Gynec. Assn., xxiii, 432. 

^ Ann. of Surg., Ivi, 60. 

* Ibid., 1S98. 

' .lahre.sVxjricht iiber die Lei.stungen u. P.syfhiatrie, lOOG, x. 

* Dcutsch. milit. Ztschr., 1904. 



284 FRACTURES AND DISLOCATIONS OF THE VERTEBRAE 

of those operated on for spinal injury, 72.5 per cent, recovered and of 
those not operated on, 24 per cent, recovered. 

The mortality from laminectomy for fractures below the sixth 
dorsal in good hands is not greater than 10 per cent. 

Technic of Operation. — As this is a serious operation it should 
not be undertaken unless indicated and should be performed with 
gentleness and careful hemostasis. The patient is placed in a semi- 
prone position, propped up with sand-bags, or is held on a special 
table with an extension for holding the head while in a prone position, 
as for craniotomy. Special attention is given to providing room for 
the respiratory movements of the chest. Frazier states that in the 
dorsal position a patient expires air in a ratio of 10 to 6 compared 
to the face-down position, and he therefore uses intratrachial insuffla- 
tion in spinal operations. The spinous process which marks the 
selected site of operation is indicated by a double coating of iodine, 
and a skin incision four inches long is made, either directly over the 
spines or in a curved line lateral to them. The mistake of opening 
too low should be avoided through recollection of the anatomical points 
mentioned in the beginning of the chapter. 

After the spines are exposed by retraction, the muscles are reflected 
on both sides by a sharp elevator or chisel, down to the laminae. The 
laminae are cut through by a laminectomy forceps or by the mechanical 
or Doyen saw, and the spines are lifted out, after a severing of the 
interspinous ligaments. Several spines may thus be removed. The 
opening into the canal may be broadened, if necessary, by a cutting 
off of more of the laminae laterally. If the saw is used it must be 
placed at a right angle to the surface of the laminae, not in line with 
the axis of the spine. This removal of bone exposes the dura. Even 
if no damage to it is seen, it should be opened or punctured by an 
aspirating needle to detect the presence of blood and to determine 
the condition of the cord. Allen's procedure may be used. Spicules 
of bone, pieces of dura, or foreign bodies are carefully picked out of 
the cord. If suture is believed in, the severed cord or the dura may 
be stitched together. Dislocations may be reduced. McWilliams^ 
reported a case with partial severance symptoms which showed clini- 
cally a projection of the twelfth dorsal spine. On opening being made, 
the articular process of the upper left side of the twelfth dorsal was 
found empty and directed up and inward. The dura seemed uninjured 
but arched over the projecting twelfth dorsal, and the transverse 
process of the eleventh and twelfth dorsal were fractured. The dis- 
location was reduced by traction on the shoulder and pelvis and a 
pushing on the opposite lumbar region to rotate the spine, and a pry- 
ing of the edge of the eleventh dorsal articular process upward with 
a periosteal elevator. It required great force to establish a reduction. 
The condition after a year and a half was that of a typically spastic 
gait but the patient could walk unassisted. 

1 Ann. of Surg., xlviii, 140. 



FRACTURE-DISLOCATIOXS OF THE DORSAL REGION 285 

The dura should be left open. The muscles are closed by a buried 
layer of sutures, the fascia also, and the skin is best closed by a sub- 
cutaneous stitch of zero catgut which does not need removal. There 
should be no drainage. 

Osteoplastic exposure of the spinal canal as described b}^ Bickham^ 
is not advisable in fresh traumatic cases. It may be used in late 
operations and has the advantage of not removing more than one 
spinous process to give a good view of the spine. Ji composite flap 
of skin, fascia, and one or more spinous processes, is raised upward 
through a U-shaped incision parallel to the spines. Hartley's pre- 
liminary excision of the spinous process at the base (upper end) of 
this lap is made through a small incision over that spine. All struc- 
tures are later dropped back, after the cord has been attended to, and 
sutured into normal position. 

Spinal puncture as a diagnostic and therapeutic means is easily 
done. This is not the place to discuss the technic, but the surgeon 
should recall that although the anterior subarachnoid space of the 
cord is entirely free and open, the posterior space in the dorsal region 
is divided by interrupting membranes attached in the line of the nerve 
roots. Lusk- has called attention to the anatomy and the paralytic 
sequels which may follow lumbar puncture. Meningitis after spinal 
operations is also treated by repeated spinal punctures in connection 
with a constricting band of Bier's hyperemia around the neck. Klapp^ 
has reported 2 cases of meningitis thus treated after gunshots, with 
recovery. 

Bone transplantation to stiffen the spine and afford support after 
fracture and laminectomy is also an operative step of value. This is 
done in accordance with Albee's method after the wound of laminec- 
tomy has healed and there is assurance of no pressure on the cord 
and full return of function. This avoids the wearing of a brace or 
plaster jacket and makes the patient nearly as independent as before 
the fracture. The transplant should cover the length of five or six 
spines a^id every effort be made to establish bony union. Palmer^ 
has reported a successful case. 

1 Ann. of Surg., xli. 373. 2 ibjd,^ ijv, 449. 

3 Miinch. med. Wchnschr., Ixii, No. 5. 
* Surg., Gynec. and Obst., 1914, p. 664. 



CHAPTER XI. 
FRACTURES AND DISLOCATIONS OF THE CLAVICLE. 

Anatomy. — The clavicle acts as a buttress between the upper extrem- 
ity and the trunk and is "f shaped with a double curve. There is 
a convexity forward at the sternal end where the bone is flattened out. 
The two extremities are composed largely of cancellous bone encased 
in a thin compacta. The area of the junction of the middle and outer 
third has a thicker compacta. It is in this weak portion where the 
two curves of the bone meet that fracture is most frequently found. 

This bone begins to ossify before any other in the body, but its 
ossification centres have little clinical bearing on fracture. At the 
outer end the trapezius and deltoid muscles are attached, the latter 
in front. At the inner or sternal end the sternocleidomastoid is found 
on the back and upper edges and the pectoralis major on the anterior 
and lower edge. Beneath the bone is the subclavian muscle, at the 
inner end is the rhomboid ligament which attaches it to the first rib, 
and at the outer end are the conoid and trapezoid ligaments which 
bind the clavicle to the scapula. The upper surface of the bone is 
subcutaneous and palpable for its whole length, and at the ends are 
found true joints with strong capsular and supporting ligaments, the 
acromioclavicular joint at the outer and the sternoclavicular joint at 
the inner end. Palpation of the acromioclavicular joint discovers 
its position medial ward from the acromion process of the scapula. 
The joint is directed obliquely and lies well within a ruler edge applied 
along the outer side of the arm projecting above the shoulder. (See 
the ruler test applied in fractures of the humerus.) 

FRACTURE OF THE CLAVICLE. 

Causes and Occurrence. — Fractures of the clavicle are caused by 
direct and indirect violence and rarely by muscular action. Most 
instances arise from falls on the shoulder, forearm, and hand, with 
the arm abducted, the stress of the impact being borne by the clavicle 
in its capacity of support of the arm out from the body. Blows on 
the elbow act in a similar manner, and the indirect violence is trans- 
mitted in the same direction, the point of fracture tending to select 
a site where there is alteration in the line of bone support. This is 
in the clavicle at the junction of its two curves. A very large propor- 
tion of these fractures occur in children. In 10,702 cases of fracture 
at the Cook County Hospital there were 538 clavicular fractures. I 
have also made a study of the fractures of children for a period of 



FRACTURE OF THE CLAVICLE 287 

seven years and find that of 1149 consecutive fractures there were 
111 of the clavicle, or approximately 10 per cent. This contrasts 
strongly with 4 cases of fractures of the ribs in children during the 
same period. Violence from falls which lead to dislocation of the 
humerus in adults cause bending and compression fractures of the 
clavicle with little deformity in children. Rarely the bone is broken 
in adults by indirect violence coming from the arm which bends the 
clavicle over the first rib. This is probably caused by action of the 
arm muscles, which suddenly overcome resistance when under great 
strain in a downward direction and pull the clavicle violently down 
across the rib. 

Direct violence may be applied at any part of the bone and cause 
fracture by compression, or dislocation by indirect transmission. 
It is usually received on the most prominent part of the bone in its 
convexity forward. Blows on the front of the shoulder directed back- 
ward usually result in transverse fracture of the clavicle, and blows 
from above directed downward near the outer end cause fracture or 
dislocation of the outer end. The ordinary direct causes are weights 
falling on the clavicular region or run-over accidents. 

Muscular action has caused some fractures of the clavicle. If the 
arm is rigidly fixed in an effort to support strain, the pectoral and 
deltoid muscles acting together might cause fracture. Extreme 
extension of the arm backward in muscular action is more likely to 
cause a dislocation forward of the sternal end of the bone than frac- 
ture. Fractures resulting from blows delivered by the arm in boxing 
or striking are really caused by indirect violence and shock of the 
sudden impact transmitted to the clavicle and are not to be attributed 
to muscular action. 

Pathology. — Fractures of the clavicle are divided into those of the 
two extremities, and those of the shaft. The contour of the bone 
also permits an easy division into fractures of the inner, middle, and 
outer thirds. 

The shaft, especially the middle third, is the most common seat of frac- 
ture, for obvious anatomical reasons (Figs. 115 and 116). This portion 
containing the junction of the two curves of the bone suffers from 
indirect violence, and the line of separation is generally oblique from 
behind forward and inward, or forward and outward. Fracture may 
assume any form of single, multiple, complete, incomplete, green-stick, 
transverse or oblique separation. Open fracture is extremely rare and 
arises from direct violence of gunshots or run-over accidents. The 
extremities of the bone are less liable to fracture or to displacement 
because they are firmly held by the various ligaments and are less 
subject to displacement resulting from muscular attachment. The 
usual break in the middle third of the })one is o})lique and complete 
in adults, and transverse in children, with varying separations. If 
the bone is broken in two places or is comminuted, the fragments may 
be displaced in any direction in which they are carried by the force. 
The same statement applies to fractures caused by direct violence. 



288 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

I have seen a fracture at the junction of the middle and outer thirds 
in which the outer fragment was turned directly downward and 




Fig. 115. 



-Complete fracture of the clavicle at the junction of the two curves seen from 
the rear. There is Httle angularity or displacement. 



assumed a position parallel to the long axis of the humerus (see Fig. 
117). It is unusual to find the outer fragment riding above or behind 
the inner fragment. 




Fig. 116.- 



-Fracture of the clavicle in a child. Seen from behind, 
to impaction. 



Note the tendency 



Displacement of the fragments is influenced by the anatomy and 
the continuance of the action of the force after fracture is accomplished. 
The inner fragment is drawn upward by the attachment of the sterno- 
cleidomastoid muscle, or pushed by the outer fragment (Figs. 118 and 



FRACTURE OF THE CLAVICLE 



289 



119), but its displacement is not great unless the rhomboid ligament 
which holds it to the first rib is ruptured. The outer fragment tends 




Fig. 117. — Usual displacement of fragments in clavicular fracture. Inner fragment 

drawn upward. 

to be displaced downward, forward, and inward either in front of or 
behind the inner fragment according to the direction of the force and 
the type of the oblique fracture. This position is aided by the 
unsupported weight of the arm and the contraction of the pectoralis 




Fio. 118. — Usual displacement of clavicular fracture in an adult. Seen from behind. 



major or deltoid muscles pulHiig the shoulder down and in when the 
clavicle supj)ort is lost. The scapula also tends to embrace the 
19 



290 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

thorax more closely when this support is lost, and the forward and 
inward position of the shoulder is favored that much more. 




Fig. 



Plate 
bent 



19. — Repair of the preceding. Note the method of bending the plate before 

attaching it. 



In transverse fracture the periosteum may not be completely torn, 
and the fragments remain in apposition but take on an angular deform- 
ity either up or down or forward or back. 

In infants and children trivial falls result in bending and green- 
stick fractures which cause little displacement (Fig. 120). The patient 
has pain and does not use the arm, but the condition may be over- 




FiG. 120. — Complete fracture in a child. A small amount of displacement. 



looked unless examination is thorough. Palpation may reveal a slight 
thickness or angular deformity directed forward and upward, and if 



FRACTURE OF THE CLAVICLE 291 

the fracture is complete there is distinct iinevenness according to the 
usnal displacement. 

Fractures of the outer third, the acromial end (Fig. 121), are next 
in order of frequency and arise from direct violence from blows on the 
shoulder from above, or indirect violence received from falls on the 
arm when the arm is less abducted than in the mechanism of the shaft 
fracture. When the arm is closer to the chest, the humerus is driven 
more directly upward. This condition usually results in a transverse 
fracture between the conoid and trapezoid ligaments, and the displace- 
ment is very little, because both fragments retain their strong liga- 
mentous attachment to the coracoid process of the scapula. If the line 
of fracture is inside of these ligaments, the inner fragment is displaced 
upward and forward with considerable separation (see Fig. 122). 




Fig. 121. — Fracture of the acromial end of the clavicle. Displacement limited by 
ligaments, (See Fig. 122.) 

A third type is found in fracture external to, or outside of, the 
trapezoid ligament. This injury is caused by direct violence applied 
at the shoulder. There may be no displacement at all because the 
conoid and trapezoid ligaments hold the outer piece in position. 
Ordinary displacement is angular. If the direct violence has been 
>evere, the outer fragment is tilted downward, loosened from the 
a(!Tomioclavicular ligament and driven by the force it may lie at right 
angles to the rest of the bone. This type is difficult to replace by 
manipulation and often demands open operation. 

Fracture of the inner or sternal extremity is unusual. It is caused 
by direct violence applied over the inner end or indirect violence from 
falls or blows on the shoulder when the arm is abducted and elevated. 
This violence usually results in dislocation of the sternal end. If the 
ligaments about the sternoclavicular joint hold, and the bone breaks, 
the Ime of fracture is generally transverse or oblique, and the (hs])lace- 



292 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

meiit is angular forward or forward and downward. This displace- 
ment is influenced by the costoclavicular (rhomboid) ligament, which 
holds the clavicle down to the first rib, overcoming any tendency to 
upward displacement from contraction of the sternocleidomastoid 
muscle. The direction of the force and the pull of the pectoralis and 
deltoid muscles may also pull the outer fragment down. 

Separation of the epiphysis of the sternal end of the clavicle, which 
unites as late as the twenty-fifth year, may be included in fractures 
of the inner end. The condition is rare. Three cases were reported 
by Hutchinson. 1 




Fig. 122. — The left shoulder and acromioclavicular joints, and the proper ligaments 

of the scapula. (Gray.) 

Complications. — Complications of fracture of the clavicle are rare. 
They consist of injuries of the brachial plexus nerves, which lie beneath 
and behind; of the subclavian artery and vein, or the internal jugular 
vein; puncture of the lung or opening of the pleural cavity by tearing 
of the upper extremity; or complications about the shoulder-joint 
from displaced fragments and interference with function. A few 
cases of brachial plexus paralysis, either primary from the contusion 

1 British Med. Jour., July 16, 1887. 



FRACTVRE OF THE CLAVICLE 293 

of the injury, or secondary from the hiter calhis pressure are reported. 
This possible coniphcation should always be remembered. Aneurism 
of the subclavian, and arteriovenous aneurism, have also been recorded, 
but are very rare. The subclavian muscle and the periosteum, as 
well as the usual displacement of the fragments, protect the important 
underlying" structures in the neck. Open and gunshot fractures and 
those accounted for by direct violence with great displacement are 
the ones followed by complications. Ununited fractures of the clavicle 
are relatively uncommon. They are usually accompanied by angular 
deformity and a distinct false joint, if of long enough standing. Func- 
tion in the arm varies, but generally becomes fair. Pain after use or 
pressm*e symptoms of the large mass at the fracture site are found. 
Fracture of both clavicles simultaneously occurs w^hen compression 
force is applied to both shoulders, as in lateral squeezes betw^een car- 
bumpers, or as in the ''death zone" betw^een street cars passing in 
opposite directions. Stimson^ mentions a case caused by a horse kick, 
a hoof being planted on each clavicle. If immobilization is considered 
inadvisable because of chest complications threatening the lungs or 
other contra-indications, non-union may follow the double fracture. 
Rest in a supine position generally takes the weight of the arms off 
the chest, helps the dyspnea, partially or completely reduces the 
deformity, and gives a good functional result. I do not believe that 
the loss of power in the accessory respiratory muscles has much 
influence on the dyspnea, because in fractures of the cervical spine 
with paralysis of all respiratory muscles except the diaphragm dysp- 
nea is rare. 

Symptoms, Diagnosis, and Course. — The symptoms of the common 
fracture of the shaft or middle third of the bone are pain, a character- 
istic attitude, loss of use of the arm, and apparent deformity in the 
clavicular area. Added to these the signs of crepitus and swelling with 
ecchymoses are nearly always present. The pain is present, both as 
localized tenderness over the site of fracture of the bone and as a result 
of attempts to move or raise the arm. The patient rests wdth the 
shoulder dropped downward, forward, and inward and there is a 
narrowing of the shoulder breadth from midsternum to the humeral 
tuberosities w^hich form the outer margin of the shoulder region. The 
patient inclines the head toward the injured side to relax the muscles 
pulling the inner fragment upward, and with the uninjured arm sup- 
ports the elbow to hold the shoulder up and to protect the broken 
bone from the jars of movement. Palpation or inspection reveals 
the overlapping deformity of the fragments, and crepitus is easily 
obtainefl, as is the false motility between them. When the over- 
lapping is very marked, crepitus may not be obtained until the shoulder 
is drawn backward and upward and the fragments brought into line. 

The loss of functional use of the arm is complete in the early hours 
after fracture and probably arises from the pain caused by the rul)bing 

' Frar-tures and Dis.lofations, 7th oflition, p. 215. 



294 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

of bono fraginents when motion is attempted. The patient always 
feels relief w^hen complete reduction is made and held and will then 
try to use the arm as much as the restriction of dressings allow^s. 
After healing of the fractures with overlapping, function in the arm is 
little impaired when use is continuously indulged in. Absence of the 
clavicle may result in a surprisingly good function of the arm. I have 
recently seen a young boy whose clavicle was completely resected for 
sarcoma. The periosteum was removed with the bone and no regen- 
eration followed. After several months he returned for implantation 
of an autogenous bone splint to act as a clavicle, but the arm function 
was excellent and was progressing, so that it was decided not to submit 
him to a second operation when he could use the arm so well. 

Infants usually cry and hold the head pressed over against the 
injured shoulder. Attempts to lift them by slipping the hands in the 
axilla cause pain, and examination can only be made when the 
child is placed flat on a table or bed and the head coaxed away from 
the flexed attitude. Fracture of the outer third is seen more often than 
that of the inner third. When the line of fracture runs between the 
conoid and trapezoid ligaments, there is little displacement. Pain 
and local tenderness are less than in fracture of the middle portion. 
The most reliable signs are a constant point of deep tenderness to 
pencil pressure and ecchymoses. It is possible in some cases to obtain 
crepitus through vigorous manipulations of the shoulder and through 
a pushing of the humerus upward. This procedure is painful and 
unnecessary. If the external fragment has been displaced downward, 
it may be felt, or its position may be seen. There is shortening of 
the shoulder breadth. Differentiation must be made from dislocation 
of the acromial end of the clavicle. In incomplete dislocation this is 
quite difficult, a roentgenogram often being necessary, if there is much 
swelling. The presence of crepitus, the greater pain located further in 
toward the midline in fracture, and a holding of the accomplished 
reduction of fractlire are the main points of difference. Complete 
dislocation of the acromial end gives an apparent deformity with 
signs of fracture absent (see Dislocation). 

Fracture of the inner or sternal third is very unusual. It is caused 
by direct violence or indirect violence from the shoulder region which 
causes dislocation of the sternal end. Line of fracture is transverse 
or oblique, with an occasional crack in the long axis of the bone. 
Displacement is usually not great. The outer fragment is held by the 
rhomboid ligament to the first rib, the inner fragment is held by the 
sternoclavicular ligaments. Additional factors causing the displace- 
ment are the untorn periosteum, the action of the pectoralis major and 
the sternocleidomastoid muscles, and the force of the shoulder weight 
bearing on the outer fragment. Whenever there is little displacement 
it is angular and downward. Where the two fragments are completely 
separated the' sternocleidomastoid contraction dominates, and the 
outer fragment is pulled upward. This fracture has the symptoms and 
signs common to those of the middle third, all points moving in toward 



FRACTURE OF THE CLAVICLE 295 

the sternum , It must be differentiated from dislocation through 
crepitus and a deformity removed from the exact end of the bone. 
There is a tendency for the deformity to remain reduced in fracture, 
and roentgenogram decides the difficult cases. Separation of the 
sternal epiphysis previously mentioned must also be borne in mind. 

The usual course of clavicular fractures is satisfactory. Within 
eight or ten days the lump of callus about the site of fracture can be 
felt, crepitus ceases, and union progresses rapidh^ If the immobilizing 
dressing has confined the elbow-joint, this may be stiff for ten or twelve 
days after removal of the bandages. Freedom of motion quickly 
returns and becomes normal. After three and a half weeks the callus 
is firm, union is strong enough to permit an attempt at functional use 
of the arm suspended in a sling. Overlapping of the fragments is 
very common; good alignment should be the rule. If a fracture at 
the ends has been overlooked and the shoulder has not been immob- 
ilized, pain is more severe after five or seven days than it was at the 
time of injury. The general prognosis is good, even with" marked 
deformity. The shortening of the shoulder breadth is often com- 
pensated by some lateral curvature of the spine and an apparently 
bad deformity with overlapping does not mean great loss of function. 
Large callus and failure of union are rare. The usual disability in 
favorable cases is ten weeks before complete return of power and use 
in the affected arm. 

Treatment. — Treatment of fractures of the clavicle is divided into: 
A, non-operative, which includes (a) recumbent and (6) ambulatory 
of both adults and children and B, operative. 

The first step in treatment is to restore the shoulder from its posi- 
tion of displacement downward, forward, and inward to its normal 
level and distance from the neck. This insures the corresponding 
normal position of the shoulder- joint and arm and of the scapula, 
which must be rotated backward and carried upw^ard until it resumes 
its former suspended position over the dome of the chest. For the 
obtaining of this correction reduction of angular deformity or over- 
lapping of the bone fragments must be accomplished, the normal align- 
ment must be resumed, and the position must be maintained until 
bony union is strong enough to hold unaided. The various methods 
of treatment which have been in use for centuries have aimed at these 
results, but no one line of care has fitted all cases or led to perfect 
results. Most important of all is the necessity of swinging the scapula 
backward to its position and at the same time elevating it. This 
result is difficult to get and to hold, especially if the patient is ambula- 
tory and the weight of the shoulder and arm counteract the correction 
of the dressing, lieduction is usually not difficult. In fracture of the 
shaft, for example, an assistant stands on the injured side slipping 
one hand over the shoulder, pulling it backward and outward to rotate 
the scapula into position, while with the other hand he pushes up on 
the elbow to raise the scapula. At the same time the surgeon, stand- 
ing in front or leaning over the seated patient from behind, manipu- 



296 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

lates the fragiiieiits by direct pressure until they are brought into 
aHgnment. If difficulty is experienced in making reduction by this 
means, the surgeon may place his knee between the shoulder-blades 
and pull on the two shoulders, or draw the arm upward and outward 
against counter-extension made on the side of the neck. These 
expedients are not often necessary, and they will fail to obtain reduc- 
tion in some cases of marked displacement of the outer fragment. 
Some displacements will yield to mild measures, especially a prolonged 
recumbent position, while others demand open operation. The impor- 
tant consideration is to maintain the correction during and after the 
application of the permanent dressing, and yet more important is it 
to ocer correct the deformity so that the shoulder is changed from a 
position of displacement downward, forward, and inward to one of 
elevation and outward rotation in which the scapula hugs the chest 
wall posteriorly, and is on a level above the bone on the injured side. 
Different permanent dressings have been advised for fulfillment of 
these requirements; the important ones will be described. Some opera- 
tors accomplish the elevation of the shoulder by placing the hand 
across the chest and pushing up on the elbow, while others effectually 
hold the shoulder outward and possibly backward, but fail to obtain 
elevation. 

A. Recumbent Treatment. — This treatment is based on keeping 
the patient in bed and allowing the weight of the shoulder to over- 
come the deformity unaided or by means of pads. The older and 
simpler method consists in having the patient lie flat on a hard, non- 
sagging mattress. The arm is lightly bound to the side, or is pushed 
upward by counter-extension applied by a band passing under the 
axilla and attached to the head of the bed. The head is slightly flexed 
toward the injured side that the neck muscles may relax. This treat- 
ment confines the patient to this position constantly until firm callus 
has formed and is a very irksome restraint. It may be supplemented 
by a narrow pad of sufficient thickness placed between the shoulder- 
blades along the spine, which will permit the scapulse to fall farther 
back in outward rotation. Straps or pads may be placed over the 
site of fracture for help in maintaining reduction. 

Modern modifications of the recumbent position contemplates 
using the whole weight of the arm hanging freely over the side of the 
bed to effect reduction. The patient is placed in a horizontal posi- 
tion so that the arm on the side of the injured clavicle hangs down 
perpendicularly over the edge of the bed and the body is held from 
slipping by a broad muslin swathe which holds it to the opposite 
side. The forearm may be supported by a sling to the side of the bed 
as suggested by Goutrand,^ or Couteaud's position may be adopted. 
This means that the perpendicular suspension of the overhanging arm 
is kept for a sufficient length of time to permit reduction of the frag- 
ments. This may require but a few hours, and if there is much pain, 

^ Bull, et Mem. de la Soc. de Chir., xxxiii, 644. 



FRACTURE OF THE CLAVICLE 297 

a few c.c. of a 1 per cent, novocaine solution are injected about the 
site of fracture. AVhen reduction is satisfactory', the forearm is bent 
at a right angle and supported on cushions, the arm alone furnishing 
sufficient weight to maintain reduction, but the greatest care must be 
exercised against movement. Oudard^ has reported enthusiastically 
on this treatment and advises that a third position be selected after 
ten or twelve days for patients who cannot endure the hanging con- 
dition. This consists in laying the whole arm alongside the body as 
in older recumbent methods without disturbing in the slightest the 
reduction gained. The bed treatment is continued for about four 
weeks, after which the patient is permitted to get up with the arm in 
a sling, and after ten days, active movements of the arm and shoulder 
follow. 

Results by these methods are uniformly good, because the callus 
is small and the reduction nearly perfect. Fractures of both clavicles 
can be treated best in this way unless there are complications which 
prohibit the supine position. Young girls or women who dread over- 
lapping deformities of the clavicle are treated thus. I have seen the 
method applied satisfactorily to a laborer with a deformity impos- 
sible to reduce otherwise. Obviously children cannot be cared for in 
this manner. Continual digital pressure to hold reduction by relays 
of attendants hardly deserves mention. I have never seen it used. 

B. Ambulatory Treatment. — This treatment is the one most fre- 
quently applied and is the only non-operative treatment which can 
be used on children. The indications for replacement of the shoulder 
in a normal position are met completely by few of these ambulatory 
appliances. They may be enumerated as axillary pads, figure-of-eight 
bandages to draw the shoulder backward, wooden or plaster cross 
splints on the back, against which the shoulders are bandaged in 
corrected position, or large mattress-like cushions used in a similar 
manner. Other splints are applied anteriorly to hold the shoulders 
back. Various bandages and- swathes or adhesive dressings are used, 
including Velpeau's, Desault's and Sayre's with its many modifications. 

Large axillary pads which act like a fulcrum to force the shoulder 
outward when the arm is bound to the side have little practical use 
because of the amount of pressure needed. This will interfere with 
circulation in the arm or make pressure on the brachial nerves, and 
the accumulation of sweat in the axilla, even when the pad is covered, 
with sterile absorbent material, necessitates frequent renewal and 
movement of the fracture. The pad is used in connection with Des- 
ault's dressing. P'igure-of-eight bandages applied around each shoul- 
rler and arm pit and across the back pull the shoulders outward and 
backward but do not raise the scapula. Their greatest fault does 
not lie so much in failure to elevate the shoulder as in the constricting 
pressure on the axillary structures and arm and the chafing of the 
skin. This defect can be partly obviated by the application of a large 

» Caduceo, 1914, xiv, 119. 



298 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

pad of saddlers' felt over the front of the shoulder, but the dressing 
becomes unstable and irritates. Figure-of-eight plaster of Paris is 
sometimes used over heavy pads. Peckham^ uses webbing straps 
stiffened with whalebone and covered with cotton flannel. These 





Fig. 123. — Velpeau's bandage for frac- 
ture of the clavicle completed. 



Fig. 124. — Desault bandage to support 
the arm without a sling around the neck 
to the wrist. 



pass around the shoulders and are laced together snugly behind. 
The difficulty with these bandages is the keeping of them out laterally 
toward the point of the shoulder. 

Velpeau's bandage is made of several three-inch muslin rollers which 
are applied to the injured shoulder after the axilla and contact area 





Fig. 12.5. — Peckham's webbing straps for 
dressing fractured clavicle. 



Fig. 126. 



-Rear view of Peckham's 
dressing. 



of the chest and forearm have been bathed in alcohol and aseptically 
padded. The hand of the injured side is placed on the opposite shoul- 
der and successive turns are made over the shoulder and across the 



1 Boston Med. and Surg. Jour., clxvi, No. 21; and ibid., clxx, 651. 



FRACTURE OF THE CLAVICLE 



299 



back and around beneath the elbow to immobihze and support the 
arm and shoulder. This dressing is objectionable in that the forearm 
and hand are boimd down tightly and cannot move, the scapula is 





Fig. 127. — Sayre's adhesive dressing, 
first strip applied. 



Fig. 128. — Side and back views of 
first strip of SajTe's dressing. 



not raised by it, and all the indications for treatment are not met. 
It becomes loose, and forearm motion works the arm out of its support, 
so that it must be reapplied frequently. 




Fig. 129. — View of the completed Sayre's dressing. Note the pad beneath the forearm 

over the chest. 



De.sault's is really an excellent means of fulfilling the requirements 
of reposition after fracture of the clavicle, if it is applied correctly. 
The bandage consists of three parts: The first holds a large pad in 



300 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

the axilla, by multiple turns about the upper chest. The second part 
passes around the chest and the injured arm causing some pressure 
inward of the elbow against the trunk, using the axillary pad as a ful- 
crum to push the shoulder outward. This endeavor has doubtful 
value, as previously mentioned, because an efficient pad would doubt- 
less cause untoward pressure on the brachial structures. The third 
part of the bandage aims to elevate the injured shoulder by holding 
it up suspended on the neck and shoulder of the well side. The fore- 
arm and hand are left free to be suspended by a light neck sling. 

Sayre's dressing is probably the best routine treatment of fractured 
clavicle in adults. It consists of two pieces of surgeon's adhesive plas- 
ter — the mole skin plaster is the best — three and a half inches wide. 
The first piece is applied over a folded pad or towel about the arm 
on the injured side just below the axilla. The plaster does not encircle 
the arm ; a space is left in the circumference on the rear and inner sur- 
face where the plaster makes a loop and is held by a safety pin or its 
own sticky surface. The free end of this arm band passes around the 
back under the opposite axilla half-way around the front of the chest 
and serves to hold the arm outward and backward to rotate the scapula 
into contact with the chest. The second piece is applied like a scarf, 
holding up the arm on the injured side by supporting the elbow, the 
weight of the arm being supported by the well shoulder. A hole is cut 
out of the plaster at its point of application over the elbow and a small 
pad covers the olecranon. By this means the shoulder and scapula 
are pushed up and backward as high as desired and the free ends of the 
adhesive covering the flexed forearm are overlapped on the opposite 
shoulder. It is necessary in this dressing, as in all dressings where skin 
surfaces come in contact, to pad well. The third part of the Desault 
bandage maj^ be applied over the Sayre dressing to give added firmness. 
The skin will not tolerate this dressing more than ten or twelve days, 
and it must then be removed, the surfaces washed with alcohol, and a 
new dressing applied. Many modifications of this dressing have been 
suggested, generally aiming to allow some freedom of the forearm and 
hand by leaving them out, or only partly including them in the second 
piece, but any looseness of the hand or forearm which permits motion 
tends to defeat the purpose of the dressing and spoils its efficiency. 
To avoid the irritation of renewal of the plaster, Collins^ has suggested 
fixing a lacing in the two pieces fastened through eyelets made in the 
adhesive plaster. The slack of stretching adhesive or looseness from 
movement of the arm may be taken up by tightening the lacing. 

The objections to Sayer's dressing are that it is very uncomfortable 
to wear the hand immobilized against the chest with possible constric- 
tion of the arm. The back pull is on the arm instead of on the shoulder 
where it should be. The adjustable modifications eliminate one 
objectionable feature (Figs. 130 and 131). 

The so-called abduction treatment meets many of the indications 

J Ann. of Surg., Iv, 88. 



FRACTURE OF THE CLAVICLE 



301 



for correct reposition. INIoorhead^ has noted that in order to accom- 
pHsh the essential point in treatment of pushing the shoulder up and 
out it is necessary to abduct the arm to or beyond a right angle. The 
farther the arm is pulled back after abduction, the easier it is to correct 
the overlapping. The technic of application of the plaster cast 
after this reduction is as follows: The patient sits on a stool with 
elbows bent to a right angle, both arms are grasped and elevated to 
or beyond a right angle and the raised elbows are then pulled farther 
back until the o^'e^lapping is corrected and the fragments are in line. 
The bod^' and affected arm are protected by flannel and a body plaster 
cast is applied with a spica over the shoulder. The unaffected arm is 



Vc- • '-^ v 




Fig. 130. — Collins's modification of 
Sa>Te's dressing M-ith eyes and lacing for 
adjustments -without removing the ad- 
hesive plaster. 



Fig. 131. 



-Back view of Collins's 
dressing. 



left free. The cast can be reinforced with strips of wood and is left 
in position for three weeks, after which the callus has developed and 
the arm can be put in a sling^ (Figs. 132 and 133). 

Infants and children very frequently sustain green-stick fracture. 
It is best to administer a small amount of general anesthesia and press 
the deformity back into normal alignment, using precaution not to 



Post-Graduate New York, 1914, xxix, 831. 
2 References for fractured clavicle: Leland, Jour.-Lancet, February 15, 1913; Hessert, 
Surg., Gynec. and Obst., February, 1910; Watson, Jour. Am. Med. Assn., February 6, 
1910, Barrell splint; Bnimwall, Jour, and Lancet, October 15, 1910; Nydigger, Jour. 
Am. Med. Assn., July 3, 1909; Bellantoni, New York Med. Jour., December 12, 1908; 
Bellamy Russel, New York Med. Jour., April 13, 1907; Hartshorn, New York Med. 
Jour., 1914, c. 1110; H. L, Taylor, Pediatrics, December, 1899; Bardenheuer, Fracturen 
der Ciavicula, die Techn. des Exten-sions verbanden 37, 1905. 



302 FRACTURES AND DISLOCATIONS OF THE CLAVICLE ^ 

overcorreet the clavicle and separate the fragments. The child's 
skin is carefully washed with alcohol, a simple desiccating or toilet 
powder is applied, and the arm is bound to the chest by a broad 
washed muslin band which is pinned snugly up the front. The forearm 
and hand are free and are supported by a light sling about the neck. 
The band is removed every other day for the inspection and cleansing 
of the skin of the chest and arm, and powder is reapplied. In three 
weeks, if the callus reaction has been satisfactory, the band can be 
left off and the arm held in a sling for a week and a half longer. Passive 
motion of the elbow and shoulder can be given when the band is 
removed for bathing, and the forearm can be massaged every day. 
In some fractures in childhood it may be impossible to correct the 
bowing of the bone. Complete fracture with separation of fragments 
usually calls for the Sayre dressing, and unusual precautions must 
be taken to avoid skiii irritation in the young patients. 




/ 

.■l 


\ 

h 

' 1. 


\^i 


.'1' 




Fig. 132.— Fayette Taylor's dressing 
for fractured clavicle. The arched band 
is metal. 



Fig. 133. — Rear view of Taylor's 
dressing, showing the large pad used 
over the scapulae. 



B. Operative treatment is used for certain indications. These 
are ununited fracture, recent fractures which are irreducible or which 
have injured or threatened bloodvessels and nerves by pressure, and 
certain cases of great comminution or multiple fracture. Simul- 
taneous fractures of both clavicles should also be operated on. The 
easy approach to the clavicle because of its subcutaneous position has 
made it one of the first bones to be subjected to operative treatment. 
This same subcutaneous position has caused many infections and dis- 
appointments in results. 

Special technic of operation on the clavicle involves but a few points. 
The incision can be. curved with base upward so that a wide flap 
of skin and platysma must be reflected before the bone comes into 
view. This is better than an incision in the long axis of the bone just 
above, because it furnishes better covering for the fleld of bone work. 



FRACTURE OF THE CLAVICLE 303 

If silver wire or kailgaroo tendon is used to hold the replaced fragments, 
it is introduced through drill holes a trifle removed from the ends of 
the bone The operator must use the drill cautiously to avoid injury 
of the subclavian vessels. Fractures of all parts of the bone have been 
plated. It would seem unnecessary to warn the operator not to 
attempt to apply a straight Lane plate to this curved bone, but I 
have seen it attempted several times. After the deformity is cor- 
rected the plate must be moulded by being bent with heavy forceps 
to the proper curve (see Fig. 119). It can then be screwed into place 
to fit perfectly. If this precaution is not taken, the operator may 
expect to find when postoperative roentgenogram is made, that most 
of his screws are not holding in the bone at all. Inlay transplants of 
bone are not often indicated in fresh fracture, unless there is great 
comminution of a part of the bone. For that purpose a curved portion 
of a rib may be utilized. 

Results of operative treatment in fresh fracture are not eminently 
satisfactory. Wire and kangaroo tendon will not hold perfect apposi- 
tion unless the external dressing is applied and kept on as in vnoperated 
cases. One must not trust to the internal splint at all. On the whole, 
kangaroo tendon gives the best results, because infection seldom fol- 
lows and the suture does not need removal. Wires are removed in 
practically all cases. I believe it is advisable in some cases to bring 
the wire out through the skin after operation and jemove it from the 
bone as soon as callus is sufficiently formed. That should be within 
two weeks, the skin wound being aseptically bandaged and the wire 
flooded daily with tincture of iodine. All Lane plates I have ever 
seen put on the clavicle have been removed for infection or irritation, 
but the bone generally heals quickly. 

L'nunited fracture may lead to no s}Tiiptoms of pain or decreased 
function. One case of ten years' standing which I saw refused any 
treatment, on the ground that there was nothing to treat, as the man 
said he could use his arm as well as he wished and there was no pain 
in the false joint in the bone. A large amount of callus around the 
site of a non-union may lead to a clinical diagnosis of sarcoma and 
pathological fracture. Treatment consists in freshening the bone sur- 
faces, removing adventitious bursse or pseudarthroses, and approxi- 
mating the fragments. Increased shortening of the clavicle may 
result. If the bone ends are attenuated and absorbed, the transplant 
may be attached so as to maintain the length present by bridging the 
bony gap instead of allowing the shortening which follows the approxi- 
mation of the freshened ends. Edington^ treated one case after a 
wiring operation ten months before. He found a thick fibrous wall 
surrounding a small cavity in which the end of the wire lay. Autog- 
enous grafts may be tied to the clavicle fragments by wire or by kan- 
garoo strands and shoukl lead to };ony union. I have operated on 
one case with good result and seen one other. I have lost the record 

1 Glasgow Med. Jour., 1914. 



304 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

of a third case of which I have recently read. An ununited fracture 
of a year's standing was treated by attaching of the ends. After 
twenty-seven days the graft was displaced and necrosed through the 
skin and was removed. After a week, blood injections were given 
weekly for a month according to Beir's method, 15 to 20 c.c. at a 
time. An excellent union followed. 




Fig. 134. — Repair of fractured clavicle with loss of bone substance by a bone transplant 

bound on. 



DISLOCATIONS OF THE CLAVICLE. 



1. Dislocations of the sternal end, forward, upward, inward or 
inward and backward. Subluxations. 

2. Dislocations of the acromial end, complete and incomplete. 
Supra-acromial, subacromial and subcoracoid. 

3. Double dislocations and complete dislocations, both ends of the 
bone simultaneously. 

The reader is referred to the remarks on dislocations of the shoulder 
region in the chapter on Fractures and Dislocations of the Humerus. 

1. Dislocations of the Sternal End of the Clavicle. — Barden- 
heuer^ found in six and a half years at the Berlin University Clinic 
that there were 400 dislocations, 16 of which were of the clavicle. 
I have reviewed a series of 775 dislocations at the Cook County Hos- 
pital in about the same period of time and find that there were 73 a| 
dislocations of the clavicle. This .makes their frequency about 9.4 ^^^ 
per cent, of all dislocations. 

The sternal end is displaced much less often than the acromial 
end. The sternoclavicular joint is an arthrodial articulation permit- 

1 Dislocations of the Upper Extremity. 



DISLOCATIOXS OF THE CLAVICLE 



305 



ting motion in nearly all directions, and the component parts are 
the sternal end of the clavicle, the upper and lateral surface of the 
manubrium sterni, and the first rib cartilage. The articular end of 
the clavicle is larger than the notch of the sternum in which it rests, 
and between the two is the articular disk of cartilage which is fas- 
tened below to the first rib. Binding this joint and giving it firmness 
are the ligaments, for the schematic representation of which see Fig. 
135. The short sternoclavicular ligaments, anterior and posterior, 
and the interclavicular ligament steady the joint, but on its upper and 
lower surface are the weak points. The costoclavicular or rhomboid 
ligament is the strongest factor in preventing posterior displacements 
of the clavicle. The anatomical construction of the joint has less to 
do with its dislocation, if we except the unguarded upper portion, than 
relaxation of the joint and the direction of the force applied to cause 




Fig. 1.35. — Sternoclavicular articulation. Anterior view. (Gray.) 



the displacement. This joint is the articulation of the shoulder girdle 
with the trunk, because the clavicle carries the scapula with it in all 
movements, the latter bone moving over the surface of the chest. 
Movements of the shoulder when it is elevated or depressed are trans- 
mitted to the sternal end of the clavicle and take place between the 
end of the bone and the articular disk, and forward and backward 
shoulder motions are transmitted between the articular disk and the 
articular surface of the sternum. Consequently elevation of the 
shoulder is checked by the rhomboid ligament and depression by the 
articular disk with the help of the interchivicular ligament and the 
first rib beneath. Sternal end dislocations are in an.y direction and 
are divided clinically into forward, or presternal, upward, and back- 
ward or inward. 

Presternal dislocations are the most common, representing from 1 
20 



306 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

to 1.5 per cent, of all dislocations of the body, according to Meyer J 
Kronlein found 5 sternal dislocations in a series of 400 dislocations. 
They are caused by pressing the shoulder backward or pulling it 
backward and outward. Pressure downward on the outer end of the 
bone also helps cause the inner end to be sprung out of place, or is 
a sole cause. The ordinary causes are falls on the point of the shoul- 
der, falls on the extended arm and hand, or forcible jerks and pulls 
on the shoulder. I had one case caused by a man slipping on a ladder, 
his arm extending between two rungs, with his body weight so sus- 
pended that the pull tended to carry the shoulder backward and 
upward, and the clavicle gave way at the sternal attachment. The 
sudden strong pull of the arm and shoulder as a whole exerts its full 
tension on the point of articulation with the trunk. The clavicle is 
pulled back beyond its limit of motion, and as the ligaments at the 
sternoclavicular joint give, the first rib beneath probably acts as a 
fulcrum to raise the sternal end forward out of its articulation. Rarely 
there are other causes from pathology in the chest arid sternal region. 
Lateral squeezes of the shoulder have caused simultaneous dislocation 
of the sternal end of both clavicles, and the traumatism of birth has 
produced dislocation in the infant. Aneurism of the aorta, spinal 
caries with deformity and violent inspiratory efforts may be enumer- 
ated as other causes. 

Pathology. — ^The condition may be a subluxation or a complete 
dislocation. In the first-named class the bone is partly raised out of 
the sternoclavicular joint, the edge of the bone or the cartilage imping- 
ing against the sternum. The anterior sternoclavicular ligament may 
be merely stretched, but more often it is shredded in part of its width 
and the posterior and rhomboid ligaments remain intact. If the 
bone is completely dislocated, its end comes to lie on the lateral or 
front surface of the sternum, or if the shoulder has been pulled violently 
backward and upward, the sternal end of the clavicle takes a forward 
and downward displacement of one or more centimeters. In one case 
on which I operated the anterior sternoclavicular ligament was torn 
irregularly across, permitting the bone to slip forward. The tags 
did not interfere with reduction in any way, and the posterior ligament 
was not ruptured. Complete dislocation with displacement may 
rupture both the posterior and rhomboid ligaments, or they may 
remain attached to the periosteum, which is stripped up to permit 
the bone to escape from the articulation. Secondary displacement 
from muscular pull can be expected when all ligamentous support is 
lost at the sternal end of the clavicle. The sternocleidomastoid is 
usually relaxed by posture, and the pectoralis major may pull the 
bone downward. Dislocations caused by shoulder changes follow 
after distention and stretching of the capsule and ligaments, so that 
an incomplete dislocation might be found with no capsular tear. The 
complications are few. Hemorrhage is usually local and small in 

1 Deutsch. Ztschr. f. Chir, Leipzig, 1912, cxix, 497. 



DISLOCATIOXS OF THE CLAVICLE 807 

amount. An inflammatory bursitis may result from the trauma. 
I had one case which proved fatal ten daj's after injury because of 
traumatic pneumonia. Dislocation of the other end or fracture of a 
portion of the sternal end of the clavicle may accompany this dislocation. 

Symptoms and Diagnosis. — Incomplete dislocations are often over- 
looked either because serious rib fractures accompany them, or the 
displacement is so slight that it is not noticed. After a couple of days 
the hematoma at the point of separation, the persistent pain and ten- 
derness to pressure directly over the joint, and the slight deformity 
compared with the joint on the other side, will make a diagnosis. 
Complete dislocations are apparent through inspection and palpation. 
The sternal end of the clavicle rides in front of the sternum; there is 
pain and deformity. Crepitus is absent, and the displacement is 
easily reduced, to recur on the slightest movement of the arm. The 
shoulder drops a little, and the head is bent toward the affected side. 
Use of the arm is at first very painful and is restricted. After a few 
days when the pain subsides more functional use results. The dis- 
location must be differentiated from fracture of the sternal end of the 
clavicle. Fracture is farther out toward the acromial end, there may 
be an angular displacement or criepitus, and if the fracture shows 
displacement the outer end of the inner fragment tends to tilt upward 
and can be palpated. Shortening of the long axis of the clavicle is not 
of much help, and in cases of fracture with little displacement, the 
roentgenogram will decide. 

Reduction and Treatment. — The integrity of the joint depends on the 
ligaments, and when they are ruptured there is nothing to hold the 
bone in place. Reduction is easily accomplished by the surgeon's 
drawing the shoulder outward and backward to elongate the distance 
from the shoulder to the sternoclavicular joint and then pressing down 
on the sternal end of the clavicle. It may suffice to draw the shoulder 
outward, the bone slipping readily into the joint and immediatel}^ 
coming out when the shoulder is released. Stimson^ mentions that 
the anatomical relation would suggest that reduction could be held 
by a holding of the shoulder forward by means of a figure-of-eight 
bandage crossing in front of the chest, which tends to press the sternal 
end into the sternoclavicular joint. A Velpeau or Desault dressing 
flescribed under Fracture of the Clavicle may hold the reposition, or 
a broad piece of adhesive may be strapped over the joint across chest 
and shoulder to hold the reduction, the arm being imm()})ilize(l through 
being bounrl to the chest. Danielsen^ has carried the idea of forward 
position of the shoulder to maintain reduction to its logical conclusion. 
He advises that after reduction the arm should be raised until it is 
in contact with the cheek and the forearm is flexed over the head and 
held there. This forces the clavicle inward and fixes it firmly in the 
sternoclavicular joint so that it cannot escape. One case which he 
treated thus gave a prompt cure. 

' Fractures and Dislocations, 7tli edition, p. 590. 
2 Centralbl. f. Chir. Leipzig, 1014, xli, loOl. 



308 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

The only other practical treatment is operative. The joint is 
approached by a semilunar incision with the base upward. The 
lacerated anterior ligament is found, the deformity reduced, and the 
ligament sutured over it. A near-by flap of periosteum or fascia may 
be used to strengthen this, or a transplanted piece of fascia lata may 
be used to reinforce it. I have nailed one case through the sternal 
end of the clavicle into the sternum after reduction. 

Treatment by immobilization of the shoulder and arm when used 
simply or postoperatively, lasts four to six weeks. Meyer^ recommends 
movements of the arm and shoulder within a week after operation and 
all movements in three weeks. Use of the arm progresses slowly for 
fear of retearing of the ligaments and renewal of the deformity. If 
recurrence ensues and the dislocation becomes habitual, Stimson's 
method of injection of alcohol about the joint may set up enough 
irritation to produce a fibrous ankylosis and good function. This 
type of case can be operated on and fixed by an ivory peg or nail after 
freshening of the bone end. 

The prognosis is good for ultimate functional use after the disloca- 
tion has been reduced and retained. The joint is nearly always per- 
manently enlarged. If reduction has not been complete, the deformity 
is more noticeable, but use of the arm is satisfactory except in those 
cases of recurrent dislocation which slide in and out and cause much pain. 

Upward Dislocation. — This type is rare. It is caused by a depres- 
sive force acting on the shoulder and outer end of the clavicle, and 
the upper weak portion of the capsule at the sternoclavicular joint 
is burst through. If the dislocation is complete and the bone is forced 
out of the joint, the mechanism is probably caused by the first rib's 
acting as a fulcrum to the force pressing down at the lateral end. The 
sternal end of the clavicle tears away from all ligamentous fastening 
and rises up behind the sternal insertion of the sternocleidomastoid 
muscle and is pushed farther inward and upward by a continuance 
of the force. It may press against the trachea, causing dyspnea. The 
meniscus probably remains adherent to the clavicle. Associated 
injuries, comprising fracture of the ribs or sternum and fracture of the 
spine, may cause death. Stokes,^ quoted by Stimson, described a case 
in which the dislocation was forward and upward and each sterno- 
clavicular joint was so loose that the sternal ends of the clavicle could 
be moved in any direction. Autopsy revealed greatly stretched and 
elongated sternoclavicular and rhomboid ligaments. A case has been 
recorded by Baldwin.^ This was an upward dislocation in a four- 
year-old girl which it was not possible to reduce, but as the deformity 
was not great and the function promised to become excellent, no open 
operation was performed. 

Symptoms and Diagnosis. — Subluxations upward are difficult to 
recognize. There is slight displacement, the long axis of the clavicle 
is directed upward when compared to the opposite side, and there is 

1 Loc. cit. 2 Dublin Med. Jour., 1852, xiii, 459. 

3 West London Med. Jour., 1915, xx, 42. 



DISLOCATIOXS OF THE CLAVICLE 309 

local pain and tenderness. Complete upward dislocation may be 
determined by palpation and inspection. If the trachea is pressed 
upon, dyspnea may b^ alarming. jNIovements of the shoulder and use 
of the arm are inhibited, because each change of position is transmitted 
to the inner end of the clavicle and causes pain. 

Treatment. — The shoulder is drawn upward and outward and the 
sternal end of the clavicle is simultaneously pressed downward into 
the joint. This may be held by an adhesive strap applied snugly 
over a pad placed on the joint. Reduction is not often difficult, unless 
the sternal end becomes entangled in the insertion of the sterno- 
cleidomastoid muscle, but maintenance is as uncertain as in presternal 
dislocation. The recumbent position with the arm at the side as used 
in fracture of the clavicle may be tried, with the interscapular pad 
added. Depression or drooping of the shoulder must be avoided if 
ambulatory treatment is used, because this renews the deformity. 
The Velpeau and Desault dressings may be used. Operative treat- 
ment should be applied to irreducible cases or to those with severe 
pressure s\Tnptoms. The insertion of the sternocleidomastoid can be 
divided and the bone replaced, held by a musculofascial flap or by 
external dressing. 

Prognosis. — The prognosis as to function is good. 

Backward Dislocation. — Backward, and backward and inward 
dislocations of the sternal end of the clavicle are the rarest forms 
of inner-end dislocations. The important costoclavicular and the 
interclavicular ligaments resist this form of dislocation. It is caused 
by direct violence transmitted by a blow or a fall on the chest when 
the sternoclavicular joint is relaxed. Indirect violence may also 
cause the dislocation by pressing both the shoulders together forward 
and inward, or by pressing one shoulder forward and dragging the 
other backward. The side of the chest opposite to the dislocation 
together with the sternum must be fixed in a steady position. This 
condition permits the transmitted force in the clavicle to burst the 
posterior capsule and ligaments and force its w^ay behind the sternum. 
Usually this state of affairs is supplemented by force pressing down- 
ward at the sternoclavicular* joint. Haehner^ reports a case in a 
cavalry officer brought about by a fall forward on his saddle. In 1856 
^Nlalgaigne^ collected 11 cases, and Haehner found 9 more, mak- 
ing 20 in all. Velpeau, Hotchkiss,-^ Geissler,"^ Delattre,^ Poland,'^ and 
Bennet,^ 3 cases. Of the 20 cases collected by Poland, 13 were due to 
indirect and 7 to direct violence. Ilotchkiss's case had the clavicle 
dislocated in front of the sternum on one side and behind on the other. 

Pathology. — The meniscus probably remains attached to the ster- 
num, anfl the end of the bone is displaced inward, or backward and 

1 Deutsch. Ztschr. f. Chir., Leipzig, 1914, cxxx, 423. 

2 Knochen Briiche, Verrenkungen, lid. ii. 

3 Jahresb. f. Chir., 1806. ■• V. LeutholU Gedenkschrift, 1900, Rd. ii. 
■• ZentralVil. f. Chir., 1907, Xd. .jO. « Lancet, July, 1SH4. 

■ Jahresb. f. Chir., 1897. 



310 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

inward, and is found between the sternothyroid muscle and the 
sternum. The posterior sternoclavicular and the interclavicular 
ligaments are torn, and the sternohyoid muscle is either stretched or 
torn from its insertion in the posterior ligament of the joint. Although 
this portion of the neck is crowded with important anatomical struc- 
tures, injury to them is rare. The bone may press against the trachea 
or esophagus and cause dyspnea or dysphasia. Emphysema from 
lung puncture and fracture of the ribs may also result. 

Symptoms and Diagnosis. — On inspection the deformity is easily 
noted. The sternal end of the bone is lacking in its customary position 
and cannot be felt, but the joint surface of the sternum can be 
palpated. The acromial end of the clavicle seems displaced 
forward, and it appears shortened. There is dyspnea, sometimes 
loss of pulse on the affected side, hiccough, and pain in the joint. If 
there is pressure on the vessels, venous congestion of the face or arm 
may be present. The arm is held rigidly and there is great pain on 
the slightest motion and a feeling of suffocation and anxiety which 
inhibits the use of the arm. 

Prognosis. — The prognosis depends partly on the complications. If 
the injury is simple and reduction is easy, there should be little per- 
manent deformity and less difficulty in maintaining reduction than in 
forward dislocation. Pressure of the head of the bone on blood- 
vessels, trachea, or nerves may demand operative interference, or 
lead to late consequences of an unfavorable character. Fixation in 
the dressing for a too brief period leads to a bulky thickening of the 
joint and prolonged weakness and uncertainty in the use of the arm. 
The tendency to recur is not great, and end-results after several months 
are fair. 

Treatment. — ^The shoulder of the affected side is drawn backward 
and outward, and reduction is usually easy. Traction on the arm with 
the first rib as a fulcrum can be tried. Haehner's case yielded to this 
treatment, and a bandage holding the arm to the side prevented recur- 
rence. The shoulder should be fixed outward and downward by an 
adhesive dressing, which should immobilize for at least three weeks. 
Rest in bed is excellent. Heller^ reported a case on which he operated, 
strengthening the capsule with a transplant of fascia and fixing with 
catgut. 

2. Dislocations of the Acromial End of the Clavicle. — Anatomy. — 
The acromioclavicular joint is also arthrodial and is surrounded by 
the capsular ligament strengthened by the superior and inferior acro- 
mioclavicular ligaments, an articular disk of cartilage and the coraco- 
clavicular ligament. This latter ligament does not anatomically enter 
in the joint formation, but it is a very important structure in acromial 
dislocations of the clavicle. It is divided into two fasciculi; the one 
lying anteriorly and laterally is the trapezoid ligament and the one 
lying posteriorly toward the median line is the conoid ligament (see 

1 Zentralbl. f. Chir., 1914, No. 11. 



DISLOCATIOXS OF THE CLAVICLE 311 

Fig. 122). The articulation is oblique or slanting, and its surface is 
fiat. The clavicle lies on a slightly higher level than the acromion. 

^Motion in this joint is of two kinds: a gliding of the outer end of the 
clavicle on the acromion and a rotation forward and backward of the 
scapula on the clavicle, the rotation being limited by the trapezoid 
ligament forward and the conoid ligament backward. This means that 
the scapula has more independence than the clavicle, which is really 
passive in its transmission of the shoulder-girdle motions to the trunk. 
When the acromioclavicular joint is made rigid, the pivot of motion 
of the upper extremity is carried to the sternoclavicular joint as pre- 
viously described. As the shoulder is carried forward the angle between 
the clavicle and scapula is closed, and the trapezoid ligament is put 
on the stretch to limit the closure. In a similar manner, when the 
shoulder is moved backward, the scapuloclavicular angle opens to 
embrace the increasing curve of the thorax, and the conoid ligament 
holds to stop this spreading. These observations can be verified by 
cutting the ligaments to obtain freer shoulder motion. Cadenat^ 
believes that it is the scapula which holds up the clavicle and not the 
reverse. When one attempts to pick up an object which lies in front 
of one, or to deliver a blow, two movements result, the first in the 
shoulder-joint and the second in the scapula and clavicle. When the 
arm reaches an angle of 45 degrees with the vertical axis in this 
movement, the acromion moves forward, because it is drawn by the 
posterior fibers of the deltoid muscle. This same movement carries the 
clavicle up and backward, stretching the posterior fibers of the acromio- 
clavicular ligament and the trapezius. 

Normal separation in the acromioclavicular joint is equivalent to 
at least 1 cm. Dislocations of the joint are complete and incomplete. 
The term ''incomplete" signifies that although the capsular ligament 
and possibly the acromioclavicular ligaments are torn, the coraco- 
clavicular ligament remains intact. In complete dislocation the nor- 
mal displacement is exaggerated, and when the patient throws the 
arm forward as described, his scapula follows, drawn by the posterior 
deltoid fibers, and as the clavicle has lost its ligamentous attachment 
to the scapula, it seems to be unusually displaced upward and back- 
ward. Likewise, in abduction movements of the arm there is a slight 
forward sliding of the acromion. This knowledge is important in 
treatment of dislocation. If the treatment results in a fixation of the 
joint, there will follow limitation of reaching and abduction move- 
ments. 

Dislocations of the acromial end are divided into supra-acromial 
or upward, subacromial, downward and behind the acromion, and 
subcoracoid, downward and forward beneath the coracoid process. 
The two latter are rare. 

In Kronlein's 400 dislocations the 16 clavicular cases were divided 
into 11 at the acromial and 5 at the sternal end. The dislocation is 

' Jour, dc Chin, Paris, 191.':;, xi, 10. 



312 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

complete or incomplete. The complete form is caused by falls from 
a height on to the shoulder region, or severe blows directed backward 
or upward and inward. A common cause in the young American is 




Fig. 136. — Incomplete dislocation of the outer end of the clavicle. 




Fig. 137. — Complete dislocation of the outer end of the clavicle. 



DISLOCATIONS OF THE CLAVICLE 313 

the trauma received in tackling an opponent in football. The full 
impact is received on the shoulder girdle, and incomplete dislocations 
are very frequent. Contraction of the trapezius and sternocleido- 
mastoid muscle acts as an aid; in tackling injuries these two muscles 
are frequently in tonic contraction, and the sudden application of the 
opponent's weight causes a decrease in muscle length, a fact which 
pulls the clavicle up at its outer end. Falls from horses or over fences 
and obstructions are also causes. Nichols and Smith,^ and Nichols 
and Richardson,- analyzed football injuries at Harvard University 
in the years 1905 to 1908, inclusive. They found that besides the 
tackling injuries another cause was the catching of a player's arm under 
a pile or a mass of men falling on an unprotected shoulder. In the 
year 1905 there were 11 cases in all, 2 of which were complete, the 
injured players finishing twenty-minute halves without complaining. 

Cadenat^ believes that the mechanism of fracture of the clavicle is 
usually caused by a transverse shock near the shoulder. For the 
obtaining of a dislocation there must be a force applied in front of 
or behind the deltoid region which bears down on the acromion. This 
force induces the scapula to rotate and tears the clavicle loose from 
the coracoid. When the force is not great there is an incomplete 
dislocation; when the force is excessive the acromion and coracoid 
are pushed farther down, the clavicle is unable to follow on account 
of the pressure of the first rib and the pull of the muscles above, the 
coracoclavicular ligaments are stretched so much that they yield, 
and complete dislocation is found. 

Pathology. — Direct knowledge of the pathology is rare, depending 
on early open operation or death from other causes. One case of 
autopsy of a complete dislocation in Stimson's service at the Hudson 
Street Hospital was reported by Bolton.^ Both the superior and 
inferior acromioclavicular ligaments and the coracoclavicular ligaments 
were torn across. In incomplete dislocations, the coracoclavicular 
ligament is not torn, but the separation of the joint capsule and the 
acromioclavicular ligaments permits a displacement as great as 2 cm. 
This is classed as a diastasis. Experimental work on the cadaver 
does not meet the conditions of actual injury inasmuch as the ligaments 
alone are subjected to tearing force and the restraining and assisting 
muscles are not acting. 

A report of the detailed pathological anatomy in 2 cases has been 
made b\' Rocher.-^ One case was of a month's standing and was irre- 
ducible. An open operation revealed no hematoma. The end of the 
clavicle lay on top of the acromion covered by the aponeurosis and 
muscle fibers of the trapezius. When these were cut away the articular 
end of the bone came into view. The cartilage had been peeled off, 
and the clavicle could not be brought down into the acromioclavicular 
joint because of the interposition of fibrous tissue on the upper border 

' Boston Med. and Surg. Jour., cliv, '4. 2 ibij. clx, 33. 

3 Jour, de Chir., Paris, 1913, xi, 16. " Ann. of Surg., 1902, p. 580. 

5 Bull, et Mem. Soc, Anaf . de Paris, 1910, Ixxxv, 725. 



314 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

of the articular surface. This tissue represented the meniscus and the 
joint capsule which had been completely pulled off the end of the 
clavicle. All was excised and reduction was then easily accomplished. 
The second case was a sixty-year-old man, who was injured by a car- 
riage and sustained a dislocation of this point with other injuries. 
Within twenty-four hours a fatal ending resulted, and at the autopsy 
the end of the clavicle was found 6 cm. above the coracoid. It had 
slid under the aponeurosis of the trapezius. The deltoid insertion 
was torn out just below its upper border and the subclavian muscle 
was normal, except that it had been denuded of its covering. The 
superficial cervical fascia and the clavicopectoral fascia were torn, 
and the capsular ligament was completely torn off the end of the 
clavicle, leaving it bare. All the capsular ligament and the meniscus 
were attached to the articular surface of the acromion. Osseocar- 
tilaginous fragments which had been torn off with the capsule were 
adherent to the edges of the torn capsule. The conoid and trapezoid 
ligaments were torn off at the corocoid insertion, but there remained 
a few intact fibers stretched up between the two insertions. There 
was little blood extravasation present, and the sternoclavicular joint 
was intact. 

After these dislocations and rupture of the conoid and trapezoid 
ligaments a process of calcification may infiltrate them and aid in 
stiffening the shoulder region. Grune^ reported a case in a male 
forty-one years old who had suffered an incomplete luxation of the 
acromial end of the clavicle. He had pain in the shoulder, especially 
when the arm was raised above a right angle. There was also slow- 
ness of movements. A roentgenogram taken after several months 
showed distinct development of bone on the under side of the clavicle 
in both of the ligaments. Grune had a second case with similar find- 
ings nine months after a blow on the shoulder. This ossification 
undoubtedly comes from a tearing out of the periosteum and the 
irritation from too early movement and use of the joint. 

Complete dislocation may become open, or the loosened end of the 
clavicle with the stripped up periosteum may aScend into the neck and 
produce great deformity. Injuries of vessels and nerves by the dis- 
located bone are almost unknown. 

Other fractures or dislocations in the same shoulder may accompany 
the dislocation. Sprain fractures with tearing out of bone shells are 
frequently seen in the roentgenogram. 

Symptoms and Diagnosis. — ^When the patient sits with the arm hang- 
ing, the acromial end of the clavicle rises higher than the one of the 
uninjured shoulder. Incomplete dislocations with slight separation do 
not show much deformity, and in recent cases this can be overcome 
by pressure down on the clavicle or upward on the arm. Crepitus 
and much swelling are absent. The trapezius and sternocleidomastoid 
muscles are in contraction and help hold the bone up out of place. 

1 Arch. f. klin. Chir., Berlin, 1911, xciv, 476. 



DISLOCATIONS OF THE CLAVICLE 315 

Complete dislocations are characterized by a greater displacement 
and possibly overriding of the acromion by the clavicle. Pain in the 
joint and loss of fnnction in the arm are variable, depending on the 
character of the causative force and the amount of displacement. 
Athletes and laboring men may not notice the disability at first. In 
a few hours pain and tenderness increase until the arm is held at rest. 

Diagnosis is made on the apparent deformity and the finding by 
palpation of looseness in the joint and of the acromion's lying on a 
lower level than the outer end of the clavicle. The deformity is easily 
overcome by the operator's lifting up on the elbow and pressing down 
on the clavicle, and it returns when the arm is dropped. Fracture of 
the outer end is differentiated by greater pain, sometimes by crepitus 
being demonstrated, and by a normal relation between the acromion 
and extreme end of the clavicle. ^leasurement of both clavicles, for 
the determination of their length and the position of the deformity, 
will also help. 

Large bone spurs and rickety deformities of the clavicle must 
also be differentiated. They are usually painless, their deformity is 
not influenced by arm movements, and they are bilateral. Contusion 
of the acromion area, bursitis, and sprains must not be overlooked. 
They lack definite signs of dislocation and usually subside with a few 
days" rest. The Roentgen picture is necessary in many cases. 

Treatment and Prognosis.^ — Reduction, especially in incomplete 
cases, is often very easy. A hand in the axilla raises the shoulder mass 
upward and the other hand presses down on the clavicle. A soft 
crepitus of the reduction of displacement is generally felt; if it is 
absent, there may be interposing shreds of capsular ligament, or the 
outer bone end may have perforated through the fibers of the trapezius. 
If this is so, complete reduction can be accomplished only by open 
operation. In severe cases of complete dislocation and great dis- 
placement the shoulder must usually be brought backward and then 
raised to meet the pressed-down clavicle. Reductions of this class are 
a great disappointment; they may seem satisfactory, but recur before 
a retention dressing can be applied, or after a few days in the dressing 
are found to be as bad as at the time of injury. Several times I have 
seen carefully applied Desault or Yelpeau bandages removed after 
two weeks' immobilization only to disclose the same old deformity 
present. 

For incomplete dislocations these two dressings mentioned may be 
used, or Stimson's dressing of surgeon's adhesive applied over the 
shoulder and around the elbow supplemented by a swathe which holds 
the arm to the side. Nichols and Smith^ used a modification of this 
dressing (see Fig. 138), and obtained satisfactory results in every 
case. Sayre's dressing for fractured clavicle is also used, with an 
xtra strap over the displaced acromial end of the clavicle. 

Nichols's modified dressing is applied after the shoulder is corrected. 

' Loc. fit. 



316 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

The first band of two-inch adhesive plaster (A) starts near the wrist, 
is carried over the padded elbow and back across the upper arm. The 



-¥■ x^r- 







Fig. 138. — Nichols and Smith's dressing for discolation of the outer end of the clavicle. 



l-\ '-■ 





Fig. 139.— Bellamy's adhesive dressing for Fig. 140.— Back view of Bellamy's 

dislocation of the outer end of the clavicle. dressing. 



DISLOCATIOXS OF THE CLAVICLE 317 

shoulder is held back while the plaster is carried up to the base of the 
neck behind and forward over the shoulder to the chest. The second 
piece (B) starts on the front of the chest, goes up over the shoulder 
one inch inside the outer end of the clavicle, down back of the arm 
around the elbow and up in front to cross the first turn of the strap 
about the middle of the clavicle. It then passes over the shoulder 
and across the back. An axillary pad is used to prevent inward 
displacement of the shoulder (Figs. 139 and 140). 

Operative treatment by wiring was first suggested and done in 
1S61 by Cooper, of San Francisco. It is often difficult to persuade 
patients of the necessity for operation for their condition when the\^ 
have little pain and a fair function in the arm. Operation, however, 
is certainly indicated when there is complete dislocation and lacera- 
tion of the coracoclavicular ligaments. Workingmen who need strong 
shoulders for work should be treated by operation even if the dis- 
placement is slight. It shortens the convalescence and gives a stronger 
joint. 

The operation done by Cooper consisted of wiring the clavicle to 
the acromion. Kreck, in 1894, wired 2 cases. ^ Later, suture of 
the ligaments was proposed, and Elmgreen^ modified the ligament 
operation by detaching the trapezius from the clavicle and fixing it 
to the first rib. Nailing was also done through the acromion into 
the clavicle,^ and the most modern operative treatment consists in 
repair of ligaments supplemented by transplantation of fascial flaps 
when necessary. ]Many authorities agree that suitable permanent 
reduction is not possible, and that even the incomplete dislocations 
>hould be operated on. Others, in view of our present knowledge of 
the sternoclavicular articulation and the shoulder movements, believe 
that operation which fixes, like nailing, or which causes an ankylosis 
of the joint, causes a greatly restricted function. Cadenat^ is one of 
these. He quotes Kappler and Pierre Marie, who saw 5 cases, in 
all of which the clavicle was completely removed or absent, with no 
loss of function. One group of 4 cases was in one family who all 
had congenital absence of the clavicle with no trouble in use of the 
arm. Opois^ reported 6 cases of total extirpation of the clavicle for 
traumatisms with little functional disturbance. 

Operations of today are of all these different types. They may be 
divided into d) direct suture, (2) syndesmopexy, (3) ligamentoplasty. 

1. Direct Sidyre. — Wires are inserted through drilled holes after 
exposure of the joint through a semilunar flap with the base toward the 
neck. Silk ligatures and kangaroo tendon are also used. Nails and 
screws can be inserted. 

I^e^ recorded an acromioclavicular dislocation in a nineteen-year- 
old boy received in football tackling. Jleduction failed, and there 
was considerable loss of function in the shoulder. A vertical incision 

■ Munch, med. Wchnschr., 1897, No. .50. 2 Zentralhl. f. Chir., 1899. 

^ Xarath in Heidelberger Klinik, 1909. * Loc. cit. 

• These de Doctorat, Paris, 1907-08. 6 Ann. of Surg., 1914, Ix, 506. 



318 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

was made over the outer aspect of the joint, and the articular disk 
of cartilage was found to prevent replacement. It was removed, and 
the ends of the clavicle and scapula were freshened. The fibers of 
the trapezius at the outer end of the clavicle were divided, and easy 
reduction followed. Fixation was furnished by three kangaroo sutures 
through the coraco-acromial ligament and clavicle and also through 
the coracoid process and around the clavicle. The arm was immob- 
ilized in plaster in a position of abduction for two weeks. The patient 
was then let out of bed and after five weeks the plaster was removed. 

2. Syndesmopexy. — The reconstruction of the acromioclavicular and 
coracoclavicular ligaments can be done by sewing their torn edges 
together with heavy catgut, kangaroo tendon, or silk. Mattress 
stitches are the best. 

3. Ligamentoplasty. — Ligamentoplasty is of use when the ligaments 
are torn and shredded beyond repair. A flap of fascia lata is trans- 
planted, or the posterior fascia along the coraco-acromial wall is taken 
and sutured down over the end of the clavicle and the acromion by 
attachment to the remnants of the ligaments. 

Ligament repair should always be done when wiring or other direct 
fixation is performed. Every operation should be followed by four 
or Sive weeks' immobilization in a Velpeau or Desault dressing until 
the joint is strong enough to start function. Results of non-operated 
cases may be satisfactory if the deformity is overlooked and the 
patient need do no manual labor. In laborers there is always' a restric- 
tion of function when a suitable repair has not been made. The 
patient loses power to lift the arm high and has weakness in abduction 
and reaching. If the dislocation is incomplete and the joint has a 
play of a centimeter there is little disability. Complete dislocation 
unreduced gradually increases with loss of strength and pain in the 
shoulder. The loss of power eventually is so much that the arm cannot 
rise above 90 degrees. Operative results and prognosis are very good. 
The disability is short and union is prompt. Recurrence must be 
guarded against. Final functional results in three months are satis- 
factory. 

Subacromial Dislocation. — Subacromial dislocation downward and 
under the acromion are rare, not more than fifteen being found in the 
literature.^ The causes are generally direct violence by falls or blows 
on the outer end of the clavicle. Allen's case was caused by muscular 
action when a girl raised an axe above her head while chopping wood. 
The head of the humerus probably aids in pushing the end of the 
clavicle back under the acromion. There is depression of the top 
of the shoulder, change in the direction of the long axis of the clavicle, 
and pain and tenderness with ecchymoses. Function in the arm is 
greatly interfered with, and the brachial plexus may be pressed upon 
with numbness and tingling in the arm and fingers. The scapula is 
rotated and raised so that its inferior angle is unusually prominent 

1 Allen, New York Med. Record, xix, 206; and Eaton, ibid., xx, 734. 



DISLOCATIOXS OF THE CLAVICLE 319 

and its motions are restricted. The clavicle seems to point downward, 
its sternal end is painful to deep pressure, the sternocleidomastoid 
and trapezius muscles are held taut, and the head inclines toward the 
injured shoulder. If the swelling is not great the empty articulating 
facet of the acromion ma}^ be palpated. 

Treatment. — ^Treatment is that of reduction and fixation. The 
shoulder is drawn outward and backward by a firm grasp and the 
chest is drawn forward by the two flat hands of an assistant. Theoreti- 
cally, extreme abduction with elevation of the arm might aid. The 
clavicle can also be grasped and raised during these manipulations. 
In the recorded cases replacement has been easy. Open operation 
would be suitable for those cases which w^ere irreducible or of long 
standing, with loss of function and pressure symptoms. The prognosis 
is fair. Function is good after reduction, and even without reduction 
the use of the arm is fair. 

Subcoracoid Dislocation. — This condition is practically unknown, 
and the cases reported, 5 by Godemer and 1 by Pinjon, later reviewed 
l\v INIalgaigne, are doubtful. The coracoid and acromion processes 
are supposed to be prominent beneath the skin of the shoulder. There 
is a depression of the outer end of the clavicle which may be felt in the 
axilla. Reduction would be made by drawing the shoulder backward 
and outward and pulling up on the clavicle. 

Double Dislocation of the Clavicle. — ^There has been some confusion 
in the literature between double and total dislocations of the clavicle. 
Double dislocation can occur in symmetrical joints only. Total dis- 
location means simultaneous dislocation of both ends of the clavicle. 

Von Kamptz^ reported a double presternal dislocation of the clavicle. 
A double dislocation of the acromial ends was reported by LeBec. 
The only case of double retrosternal dislocation was seen by Geissler 
in a fifty-year-old man who fell about fifteen feet. Von Kamptz's 
case could not be reduced by manipulation, and open operation was 
resorted to. An instance of bilateral congenital sternoclavicular dis- 
location was reported by Gourdon.^ In his article he states that 
Ferguson saw a similar case caused by accident during birth, and that 
Shaw has reported one of an anterior congenital dislocation of one 
side. Kappler noted a luxation of the internal extremities of both 
bones in an individual in whom there was congenital absence of the 
external extremities of the clavicle. Gourdon's patient presented a 
globular enlargement of the internal extremities which could be easily 
palpated as the ends of the clavicle. The condition was painless, 
and when the shoulders were thrown forward the sternal ends disap- 
peared into their joints. The absence of the articular cartilage disk 
is believed to play an important role in establishing the continuity 
of this articulation. In congenital dislocations it is found that this 
cartilage is unstable. Gegenbauer remarked on its variability of form 
and dimension and its inconstant presence. Before the Anatomical 

' Med. Klin.. Berlin, 191.3, p. 991. 

2 Revue d'Orthoped., Paris, 191.3, 3 S., iv, '.iOo. 



320 FRACTURES AND DISLOCATIONS OF THE CLAVICLE 

Society of Paris, Poirier showed 2 cases of complete congenital absence 
of this cartilage. Unsatisfactory results have followed most opera- 
tions for this condition. Gross and Brodier sutured the sternum to 
the clavicle. Hodgen performed an arthrodesis, but Gourdon did 
not operate on his patient because there was such good use of the arm. 
Total Dislocation of the Clavicle. — There have been no cases of this 
dislocation recorded since Cousins,^ which was the twelfth. His case was 
a total dislocation upward and forward of the right clavicle, the left 
being fractured. These cases are briefly: 

1. Richeraud and Gerdy.^ This was reported by Porral, an interne. 
The patient was twenty-four years old and the bone was dislocated 
forward and upward. There were fractured ribs accompanying the 
clavicular injury. 

2. Morel-Lavallee.^ The patient was forty years of age. Both 
ends were dislocated forward and upward. The other clavicle was 
fractured. 

3. North.^ The patient was fourteen years old. Both ends were 
dislocated forward. 

4. Hutchinson.^ A man had been caught between an engine and a 
platform. There were other injuries. 

5. Stanley Haynes.^ The case was that of a thirteen-year-old girl. 

6. Col.^ The patient was a girl aged seventeen years; both ends were 
dislocated forward. 

7. Lund.^ The patient was a man aged thirty-two years. Both 
ends were dislocated forward. 

8. Rombeau.^ The case was one of dislocation of both ends forward. 

9. Hulke.!*^ This was reported by Hudson, his house surgeon. The 
sternal end was displaced forward and the acromial end backward and 
inward. 

10. Newman^^ reported a case four years after seeing it. The patient, 
a man twenty-four years old, had also ribs and opposite clavicle frac- 
tured, and retention of urine. He was never able to do hard work 
again. 

11. Lucas. ^^ This case was very unusual, becgiuse it was a simul- 
taneous dislocation of both ends in a thirty-two-year-old man who was 
caught between two cart wheels and crushed. There was a marked 
round prominence at the outer end of the right clavicle, which stood 
up an inch above the acromion. The skin was so stretched over it 
that there was danger of its bursting through. At the inner end the 
clavicle was displaced backward and downward and left a deep notch 

1 Jour. Am. Med. Assn., 1906, p. 19. 

2 Jour. Univer. et Hebdom. de Med. de Chir. Pratique, 1831, ii, 81. 

3 Gaz. des Hopitaux, 1859, No. 33, p. 130. 

4 New York Med. Record, April 16, 1866. 

6 Lancet, 1871, ii, 711. « British Med. Jour. 1872, i, 99. 

' Gaz. des Hopitaux, 1872, No. 112, p. 893. 

8 British Med. Jour., January 24, 1874, i, 106. 

9 Bull. Gener. de Therapeut., 1874, p. 538. 

1" Lancet, 1885, ii, 245. " Lancet, 1885, ii, 524. 

12 Guy's Hosp. Reports, 1889, xlvi, 445. 



DISLOCATIOXS OF THE CLAVICLE 321 

in the sternal joint. The shoulder fell downward and backward, and 
there existed a deep hollow in the lower part of the neck and the upper 
part of the chest. The two upper ribs were also probably dislocated 
backward, but there was no hemoptysis or surgical emphysema. 

Nine cases have been in males and three in females, the ages varying 
from thirteen to forty years. The causes have been external violence 
on the upper and back part of the shoulder, except in one instance; 
usually severe crushes often accompanied by other injuries. The 
shoulder may be caught between opposing forces and the clavicle 
squeezed out like the pit from a cherry. Haynes's patient, an over- 
grown girl of tuberculous tendency, dislocated the bone while washing 
her neck. The displacement is generally the acromial end upward 
and outward, riding on the acromion, the sternal end forward and 
upward. 

Good reductions were made in half the cases. Cases 2, 5, 6, and 
11 were not reduced at both ends. Lucas's case probably had a pri- 
mary reduction, but the patient left the hospital in a plaster dressing, 
suffered another accident in two weeks in which he felt something 
slip in his shoulder, but did not return until after four weeks, at which 
time the original deformity had partly recurred. The acromioclavicular 
end is reduced by the operator's carrying the elbow upward, the 
shoulder back and outward. The sternal end, if displaced forward, 
is reduced in the same manipulation by direct pressure. Lucas first 
reduced the acromial end and then made use of the clavicular origin 
of the pectoralis major muscle to draw the sternal end upward and 
forward, the arm being rotated outward and then drawn backward. 
This caused a replacement, but the bone tended to slip back out of 
place again. 

An axillary pad is applied, and the arm can be bandaged to the chest, 
or a plaster dressing can be put over all. Hutchinson's case was 
treated by rest on the back, as was also Cousin's, supplemented by 
sand-bag pressure over the dislocated joints. 



21 



CHAPTER XII. 
FRACTURES OF THE SCAPULA. 

Anatomy. — The scapula is an important link in the shoulder-girdle 
structures. Description of its peculiar shape and muscular attachments 
is not necessary. It is known to originate from at least seven centers 
of ossification, and the body plate is so thin that it is transparent, 
or in some cases, lacking entirely in bone. The greatest interest 
in the bone from a standpoint of fracture exists in the acromion and 
coracoid processes and the glenoid cavity. There is a separate center 
of ossification for the acromion, but part of it is formed by an exten- 
sion of the spine. The upper third of the glenoid cavity arises from 
a separate ossification center, as does also the coracoid process. Not 
only do these epiphyses not unite until about the twenty-fifth year, 
but bone continuity may never be established, fibrous union persisting 
throughout adult life. 

Examination of the shoulder demonstrates the outline and position 
of the scapula. The spine, the acromial and coracoid processes, and 
the vertebral and axillary borders of the bone can be palpated. It is 
impossible to obtain satisfactory palpation of the glenoid cavity and 
its edges. 

Fractures of the scapula are rare and are always caused by great 
violence. The bone is protected by heavy muscular layers on both 
surfaces, and the chest dome on which it rests is elastic enough to 
take up jarring force. The immobility of the bone in connection 
with shoulder movements is also a protection. The overhanging 
acromion and coracoid suffer in trauma more often than any other 
part of the bone; fractures of the neck and body are rare. 

In my collection of 11,302 fractures at the Cook County Hospital 
I found that the scapula was fractured 81 times, about 0.7 per cent, 
of all fractures. Of these 81 fractures, 19 were specified as acromial; 
most of the others were of the spine, body, or glenoid. Mencke^ col- 
lected all the acromion fractures for eight years, 1905 to 1912, at the 
German Hospital, Philadelphia. He found 89 cases. The fractures 
of the scapula are divided into those of the body, spine, acromion, 
coracoid, glenoid cavity, neck, and angles. 

1. Fractures of the Body of the Scapula. — These are infrequent, 
the line of fracture usually passing horizontally from the vertebral 
to the axillary border in the infraspinous fossa. The fracture may be 
multiple, comminuted, or of any irregular formation. Displacement 
is usually not great, because the fragments are held in place by muscles, 

J Ann. of Surg., lix, 233. 



FRACTURES OF THE BODY OF THE SCAPULA 



323 



and because of the great violence which breaks the bone, fragments 
may be separated and caused to override and may persist in their 
displacement in spite of manipulation. In a transverse or oblique 
fracture of the body when displacement is present it is greater on the 
axillary border. This overriding is in the anteroposterior direction, 
and the lower fragment may also be pushed laterally by the causative 
force and held upward by the serratus magnus muscle. Muscular 
action also may cause fracture of the body of the scapula, just as it 
causes fracture of the inferior angle by contraction of the teres major. 
S3miptoms and Diagnosis.— There is pain in the scapular region, 
intensified on movement of the arm and shoulder. If there is separa- 
tion and overriding of fragments, deformity in the scapula or its 




Fig. 141. — Fracture of the body of the scapula originating on the axillary border. 

borders is apparent, there are local tenderness, swelling, and ecchy- 
moses with abnormal mobility. The inferior angle of the bone can 
be grasped by one hand, while the other hand steadies the spine or 
the shoulder, and the fragments can be moved. Crepitus is also com- 
monly present. If the patient is very fat or muscular, the abnormal 
motility and crepitus may be demonstrated by the attendant's plac- 
ing the flat hand firmly on the inferior angle of the bone and then 
adducting and elevating the arm. This movement drags the upper 
fragment with the shoulder girdle and demonstrates its freedom of 
motion from the lower fragment. In very thin patients the line of 
separation may be palpated, but the opposite scapula must also be 
felt if errors caused by normal ridges on the bone are to be avoided. 
The pain on active attempts to use the arm is a constant symptom 
and may reduce the arm function to nothing. Examination will 



324 FRACTURES OF THE SCAPULA 

reveal a normal humerus and shoulder girdle and the local tenderness 
in the scapula. If the cause has been a severe violence like a run- 
over accident, the fracture of the scapula may be complicated by other 
injuries, usually involving the ribs or spine. Open fractures are rare, 
and infection is particularly to be feared in this region. The accom- 
panying injuries and shock may make the fracture secondary. The 
usual course is uneventful, the fracture heals with little deformity, 
and should overlapping fragments unite without reduction, function 
is generally satisfactory. I have seen one case of fracture of the 
scapula with an excess callus on the costal surface which prohibited 
freedom of motion and caused pain by pressure. 

Treatment. — If there is no separation of fragments and the fracture 
is comminuted, the arm and shoulders on the injured side must be 
immobilized three or four weeks in a natural position by the side. 
When there is overriding of fragments in oblique or transverse frac- 
tures, or the line of fracture runs through the spine, the misplaced 
portions of the bone may be brought into normal relation by manipu- 
lation of both the arm and lower fragment simultaneously. When 
a reduction is accomplished the arm must be immobilized in the 
position which obtains reduction. This is usually abduction, and 
elevation and an axillary triangle, or the plaster dressing described in 
the chapter on Fracture of the Clavicle, may be used. A small amount 
of displacement can be corrected by manipulation and pressure and 
can be held by a broad swathe of adhesive plaster placed about the 
chest from a point on the well side of the spinal column over the 
injured scapula and around on the anterior surface of the chest. The 
arm is prevented from moving and dragging the scapula by muscular 
action through being enclosed in a sling. 

Operative treatment is applied to open fractures and to those cases 
of marked overriding which cannot be held in reduction by strapping. 
Open fractures are treated in accordance with the line of treatment 
advised under operative treatment, with particular attention to early 
thorough drainage and removal of fragments when suppuration 
starts. Closed fractures are sometimes wired after open reduction. 
I have seen two cases, both of which gave excellent results. 

2. Fractures of the Spine of the Scapula. — Isolated fractures of 
the spine are uncommon (Fig. 142). The spine is frequently involved 
in comminuted and oblique fractures of the body, or in severe frac- 
tures of the acromion. Diagnosis is easily made on the signs of ten- 
derness, swelling and ecchymoses, and the palpation of a loose piece 
of the scapula spine. If no other parts are involved, the spine may be 
strapped in position by an adhesive or cotton swathe run diagonally 
across the back and over the shoulder. The arm on that side must be 
immobilized by a simple sling or a Desault bandage and kept quiet 
for three or four weeks. 

3. Fractures of the Acromion. — These are most common injuries 
of this bone. Mencke, as cited previously, found 89 in eight years 
in one hospital. Roentgen- ray examination of injured shoulders dis- 



FRACTURES OF THE ACROMION 



325 



covers them in a surprisingly large percentage of cases. They may 
be divided into: 

(1) Sprain fractures, caused by ligamentous or muscular tearing out 
of the bone surface. 

(2) Epiphyseal separations. 

(3) Distinct fracture of a large part of the process. 

]\Iencke found in 40 cases examined by the Roentgen rays that 25 
were sprain fractures, 8 were distinct fracture of the process, and one 
was an epiphyseal separation. Six cases were not traced. This dis- 
position of fractures corresponds with the findings at the Cook County 
Hospital, where most of the acromial injuries are sprain fractures. 
These fractures are caused bv direct violence of blows or falls on the 




Fig. 142. 



-Transverse fracture of the scapula involving the neck, body and spine. 
There is an accompanying fracture of the clavicle. 



shoulder; by indirect violence received from the head or greater 
tuberosity of the humerus, and from muscular and ligamentous pull 
in falls, blows, and dislocations about the shoulder. 

f 1 ; Sprain Fractures. — These represent the largest number of acromial 
injuries and are of interest on account of the long disability which 
follows neglected cases. The following classes can be differentiated 
according to location or cause: 

(a) yit the hhHertion of the Coraco-acromial Ligament Cavsed by Direct 
Violence Involving this Ligament. The insertion is partly torn loose 
from the acromion; rarely a fair-sized splinter of bone is detached 
with it, to make in the roentgenogram a distinct separate shadow 
which lies anteriorly to the acromion. If no distinct bone fragment 
exists, the edge of the acromion is roughened, and after a few weeks 



326 FRACTURES OF THE SCAPULA 

small calcification masses appear. Disability is caused by pain and 
stiffening of the deltoid muscle. Treatment is prolonged rest with 
baking or hot applications followed by active exercises when pain is 
entirely absent. The ultimate prognosis for shoulder movement is 
good. 

(6) At or About the Acromioclavicular Joint. These sprain frac- 
tures are caused by direct violence or indirect violence like that 
causing dislocation of the acromial end of the clavicle. They are 
similar to the first class in appearance, the tenderness is located at 
the acromioclavicular joint, and they are differentiated merely by 
position. Disability arises from pain, and as the capsular and acromio- 
clavicular ligaments are involved, pressure or tension on the clavicle 
may elicit extreme tenderness in the joint. Treatment is as for (a). 

(c) On the Upper Surface of the Acromion. These are caused by 
direct violence like that received in injuries from falls, as a sliding on 
the shoulder-joint. They are very small roughenings of the bone, can 
be found only in a carefully viewed dried plate, and are not common. 
The disability is temporary. 

(d) At the Top or Outer Surface of the Acromion. These are caused 
in two ways: The first is direct violence received on the extreme tip 
of the process, which splinters off the bone surface, and the second 
is indirect violence received by the acromion in the course of shoulder 
injuries. Fractures of the clavicle, dislocations of the acromial end 
of the clavicle, and dislocations of the shoulder cause all these sprain 
fractures indirectly. That is, shoulder injuries caused by abduction 
of the arm may injure the acromion by tearing out the ligaments, by 
springing the acromioclavicular joint, or by putting so much strain 
on the coraco-acromial joint that the great tuberosity of the humerus 
is applied forcibly to the acromion and breaks off a splinter by leverage. 

The disability which threatens from secondary arthritis or peri- 
arthritis of the shoulder- joint is like that of all joint fractures, and 
although these lesions seem insignificant, the complications and loss 
of function demand early diagnosis and the institution of joint rest. 
Treatment is the rest and baking mentioned, and must be long con- 
tinued. 

Traumatic bursitis, which has a slower onset and is characterized 
by a slightly abducted position of the arm for relief of pressure on the 
disturbed bursa, must be differentiated. 

(2) Epiphyseal Separations. — ^These are rare. They occur following 
any of the different mechanisms mentioned, more, often the abduc- 
tion strains of falls. There is a line of separation of varying width 
near the base of the acromion, tenderness, swelling and ecchymoses, 
and no crepitus. In studying the roentgenogram, cases of non-cal- 
cified union must be remembered. Treatment is rest and support of 
the arm in a sling or Desault bandage, the displacement usually being 
very small. 

(3) Fracture of the Process as a Whole. — These fractures involve a 
distinct fragment at the outer end of the whole process well down into 



FRACTURES OF THE ACROMION 



327 



the spine. The ordinary line of separation is oblique and is ontside 
of the acromiocla\icular joint. The causes are falls on the shoulder, 
direct violence of blows, or the indirect violence of abduction shoulder 
injuries, which force the humeral head directly upward or cause a 
leverage action of the tuberosity. There is localized pain, swelling, 
and tenderness. Crepitus is sometimes present. The palpating fingers 
may feel the loose fragment, and when the line of fracture is through 
or inside of the acromioclavicular joint there is a flattening of the 
shoulder on its superior aspect. The humeral head can be felt in the 
glenoid, the arm is not lengthened, and pushing up on the elbow does 
not decrease the deformity. This finding aids in differentiation from 
subglenoid dislocation and fracture of the glenoid neck. 




Fig. 14.3. — Fracture of the acromion process with little separation. 



Treatment. — The treatment consists in the immobilizing of the 
whole upper extremity with the forearm left free in a sling. The 
Desault bandage, or one of those described under Treatment of Frac- 
ture of the Outer End of the Clavicle, is excellent. The reduction is 
made by the attendant pressing the arm upward against the acromion 
to relax the pull on the small fragment, aiding the reduction by external 
manipulation of loose fragments. The supporting bandage must be 
left on at least four weeks. When non-union results, or the fragment 
cannot be replaced, open operation is indicated for the holding of the 
bone by wire, or the removal of small fragments which threaten inter- 
ference with shoulder-joint movement. Old cases with restricted 
abduction, which have been imperfectly reduced and in which bony 
union in malposition has resulted, are to be operated upon. It is 
better to remove entirely fragments which interfere with arm motion 
than to attempt to replace and fasten them with foreign material. 



328 



FRACTURES OF THE SCAPULA 



4. Fractures of the Coracoid.— These are frequent and are caused 
by direct and indirect violence and muscular action. Examples of 
direct violence are falls, football tackling and blows, and trauma 
from a dislocated head of the humerus. Indirect violence occurs in 
the abduction injuries at the shoulder and fractures of the clavicle. 
Muscular contraction of the biceps and coracobrachialis is a cause in 
severe exertion with the arm. Sprain fractures of the coracoid also 
occur following direct violence. Skillern^ has reported a case in a 
football player. I have seen several. The mechanism is probably 
a tearing out of the coracoid insertion of the coracoclavicular liga- 
ment, and the extreme tip of the bone is not involved (Fig. 144). 




Fig. 144, — Fracture of the coracoid process with dislocation upward of the outer end 
of the clavicle. The acromioclavicular ligaments have partly held. 

The site of ordinary fracture is near the base; displacement is 
slight because the coracoclavicular ligament holds the fragments. 
As in the acromion process, the ossification centre of the coracoid 
process may be split apart, or its failure to calcify may lead to diagnosis 
of epiphyseal separation or fracture from the roentgenogram. The 
plane of fracture may involve the base of the process and extend into 
the glenoid cavity. This fracture is caused by extreme direct violence. 
The symptoms are pain and tenderness on pressure, augmented by 
manipulation of the process. Swelling and ecchymoses appear, the 
discoloration spreading downward over the skin of the chest. I have 
at this time a patient with a fractured coracoid and other injuries, 
who has severe pain on slight pressure of the process and an ecchy- 

1 Amer. Jour, of Surg., Ivii, 280. 



FRACTURES OF THE NECK AND GLENOID CAVITY 329 

mosis extending below the nipple on that side. Crepitus may be 
elicited in some instances, but the displacement is slight. Bony union 
is not the rule and function of the arm and shoulder is little influenced. 

Treatment is replacement of the fragment and immobilization of 
the arm, as in fracture of the acromion. If the forearm is flexed, the 
muscles leading from this process are relaxed and pain is lessened, while 
bony union is favored. 

5 and 6. Fractures of the Neck and Glenoid Cavity. — Fracture of 
the neck of the scapula is rare, the line of fracture passing from the 
suprascapular notch to the axillary border of the bone below the 
glenoid rim. These two types of fracture, neck and glenoid cavity, 
are grouped together because one sees them together. The line of 
fracture may start in the glenoid and pass obliquely to the axillary 
border of the bone, or the base of the glenoid may be comminuted. 
The lesser fractures of this region involve the lip of the glenoid, and 
though many of them are found in dislocations of the humerus, some 
are unrecognized after trauma and lead to stiffened shoulder-joints. 

Gross fracture through the neck may cause separation of the cora- 
coid process with the broken-ofT fragment. The acromion remains 
intact and by its ligamentous attachments limits the amount of dis- 
placement downward of the glenoid and neck. 

The causes are direct violence or abduction shoulder injuries result- 
ing from falls. The symptoms of scapular neck fracture are a flat- 
tening of the shoulder area below the acromion, which stands out 
prominently, and a lengthening of the arm. There is usually pain 
and swelling with crepitus when the humerus is rotated by a grasping 
of the elbow, and the condition is most often mistaken for dislocation 
of the shoulder. It is differentiated by the surgeon lifting up on 
the elbow to reduce the deformity and by not finding the head of the 
humerus in the axilla. Duga's test is negative. When the elbow 
support is removed, the arm drops again, and the deformity returns. 
This is a characteristic finding. In a case which I saw recently the 
following additional signs were noted: 

Gentle rotation of the arm demonstrates that the head of the 
humerus rotates with the shaft, and there is little pain. If one hand 
is used to steady the scapula by pressure over the spine and shoulder, 
the other hand can raise the arm independently without causing the 
shoulder to rise. Some individuals normally possess lax joints, and 
there may be a small amount of normal motion of the humerus upward. 
This normal condition must be excluded. A roentgenogram taken 
through the shoulder at an angle of 45 degrees from the vertical axis 
of the arm will demonstrate the glenoid edge and part of the cavity. 

Fracture of the glenoid lip and edge is not uncommon. In the 
last year I have seen four, one in connection with an old partial dis- 
location in which the humerus lay slightly forward of the glenoid. 
It could not be reduced by manipulation, and open operation dis- 
closed the anterior and inferior edges of the glenoid cavity broken oft' 
and displaced downward. 1'here was no means of holding the head 



330 FRACTURES OF THE SCAPULA 

of the humerus in the shoulder-joint in a normal position, on this 
account and also because of periarthritic tissue thickening. The edge 
of the glenoid was chiseled off, part of the humeral head on the inner 
side was also chiseled off, and a muscular flap interposed. The result 
was fair functionally. Later I operated on a second case in which the 
pathology was that of a bony ankylosis caused by fracture of the 
glenoid rim. There was no history of dislocation. Beasly^ reported 
a case of a fragment broken off the lower edge of the glenoid which 
tipped enough after union to force the head of the humerus up against 
the acromion. He does not state what position the arm was in but 
does mention that abduction was painful and restricted. The adhe- 
sions were broken up and the arm placed in a normal position. Good 
function resulted. 

Treatment. — Treatment of recent glenoid fractures is immobiliza- 
tion of the arm in partial abduction until all soreness and pain have 
ceased in the joint. This will take five or six weeks, and if the primary 
rest of the joint has been thorough, fuller function will return rapidly. 
If joint motion is commenced before the process of callus formation 
and union have ended, irritat on will follow, and there will be restricted 
joint movement with pain. The old cases will improve under the 
modified arthroplasty previously mentioned. Forcible breaking up 
of adhesions and movement under anesthesia is a questionable pro- 
cedure. In some instances satisfactory results may be obtained. 
Usually a firmer ankylosis follows. 

7. Fractures of the Angles of the Scapula.— These fractures are 
rare, and really belong to the class of fractures of the body. They 
are produced usually by direct violence, although fracture of the 
inferior angle has been recorded arising from muscular action of the 
teres major muscle (Grimard).^ The displacement is generally pro- 
nounced enough to be easily detected by palpation. There is pain 
and tenderness and crepitus, with the finding of a loose piece of bone. 
The attached muscles tend to maintain displacement, so that reduc- 
tion is difficult and maintenance is almost impossible. Adhesive 
strapping and arm immobilization may suffice, because there is little 
disability following union with displacement of fragments. Open 
operation with wiring may be performed to obtain an anatomical 
reduction. 

Fractures of the upper angle are very rare and are caused by direct 
violence. The line may be but a fissure, or the fragment may involve 
the spine. Treatment is the same as the spine fractures. 

1 Railway Surg. Jour., 1914, p. 260. 

2 Arch. Gen. de Med., April, 1896. 



CHAPTER XIII. 

FPiACTURES AND DISLOCATIONS OF THE RIBS 
AND COSTAL (WRTILAGES. 

Anatomy. — Along the vertebral border the heads of the ribs articu- 
late with the bodies of the two adjacent vertebra? with a small joint 
surface and a strong ligamentous attachment. The neck and tubercle 
are also attached by ligaments and articulate with the transverse 
process of the vertebrae. The bodies are flat and curved. In front 
the rib extends into its costal cartilage directly without the interposi- 
tion of a joint. The chondrosternal articulations, except that of the 
first rib, are true joints and are strengthened by the overlapping of 
the periosteum and articular ligaments. Between the costal cartilages 
from the fifth to the ninth there are also small synovial surfaces which 
are strengthened by ligamentous bands. The costal cartilages are 
composed of hyaline cartilage; the first seven prolong the ribs forward 
to the sternum, the eighth, ninth and tenth are articulated with the 
lower border- of the cartilage above, and the eleventh and twelfth, 
end in the lateral abdominal wall without anterior attachment. These 
ribs are called the ''floating ribs." The cartilage is broadest at the 
rib end, tapering toward the sternum, and the intercostal distance 
gradually narrows from above downward. There is no fixed relation 
between rib length and cartilage length, as the cartilage gradually 
increases from the first rib to the seventh or eighth, the most promi- 
nent ribs, where it is between five and six inches long. The ribs ante- 
riorly are easily palpated and can be identified except in fat persons. 
They are elastic, and the elasticity of the costal cartilage enhances 
this property. The clavicle protects the first two ribs; the last two 
are protected because of their floating character. 

Causes of Fractures and Dislocations of tte Ribs.— The relative immu- 
nity of the first two and last two ribs protects them, and most fractures 
occur in the middle ribs, the fourth to eighth. In childhood the bones 
and cartilages are so elastic that fracture rarely occurs. In 11,302 
fractures admitted to the Cook County Hospital there were 883 frac- 
tures of the ribs, the number not quite equalling the number of 
fractures of the femur. The average age of the cases admitted during 
1914 was forty-three years. By far the larger percentage is in males, 
about 77 per cent., on account of exposure and occupation. 

The exciting causes are direct violence from falls or blows, and 
indirect violence by bending and compression, or, rarely, by muscular 
action. If the force is applied directly against a rib, it breaks by the 
usual method of compression. Infraction is rare. If the whole chest 



332 



FRACTURES AND DISLOCATIONS OF THE RIBS 



is compressed, as it is in most cases, the indirect violence may cause 
the rib to give at a weak point, usually just in front of the angle. 
Anteroposterior compression tends to flatten out the normal curve 
of the rib, which naturally gives way at the point of greatest bending 
near the angle. Muscular action may cause fractures or dislocations 
in one lifting heavy objects, straining against a heavy burden, or 
violently sneezing, coughing, or laughing. The roentgenogram has 
proved in many cases that multiple fractures of the same rib or ribs 
are more common than clinical diagnosis would indicate. 




Fig. 145. — Complete fracture of a rib with some displacement, 
is broken across but not displaced. 



The neighboring rib 



Pathology. — Fracture of a rib may be partial or complete (Fig. 145). 
The former is rare and consists of fissures or linear cracks across the 
bone with no separation. Complete fractures may be single or multiple, 
involving any number of ribs to the extent of all on one side of the 
body, or even on both sides, an occurrence which has been recorded 
in a few instances. The line of fracture is commonly transverse or 
oblique; it may be very irregular and jagged. The first two ribs are 



PATHOLOGY OF FRACTURE OF THE RIBS 



333 



seldom broken, but they may be involved in fractures of the clavicle 
or sternum, or are broken alone when violence causes depression of 
the clavicle (Fig. 146). 

Single fractures usually involve the rib at points from the mid- 
axillary line forward, particularly because they are most often caused 
by direct violence, and the scapula and heavy back muscles protect 
the ribs posteriorly. If there are multiple fractures, or the cause is 
indirect violence from chest compression, the angle is a favorite site 




Fig. 146. 



Multiple rib fractures involving even the first rib which is rarely injured. 
The clavicle is also broken. Looked at from in front. 



of break. Direct violence may cause fracture of several ribs in front 
at the point of application, and as the force continues, pressing in on 
the bones, a second fracture occurs in the weak point behind. If 
.several ribs are broken thus, the bones override, and a flat area of the 
chest is found. If the ribs are broken at one point, they may override 
slightly, the fragments assum'ng a slight angular deformity. Usually 
the periosteum is not ruptured on both sides, and this protection, 
coupled with that afforded by the muscles and neighboring bones, 



334 



FRACTURES AND DISLOCATIONS OF THE RIBS 



prevents much displacement (Fig. 147). When a single rib is frac- 
tured, overriding is rare, but it does occur. I recall distinctly finding 
a healed rib fracture in the chest wall when removing the thoracic 
organs at an autopsy. Only one rib gave any evidence of fracture, and 
that was healed with overlapping of nearly a half -inch. 




Fig. 147. — Multiple fractures of the ends of the lower ribs with loose fragments. 



Open fractures of ribs are not common. It is doubtful if the bone 
fragments ever penetrate the skin after injury, but they frequently 
penetrate the parietal pleura or the lung. The fractures can therefore 
be opened in either direction, the opening through the skin surface 
being practically always caused by the object which produced the injury. 

Complications. — Pleura and lung may be injured together or sepa- 
rately. Bone fragments are often driven through the parietal pleura, 
or the depressing of the bone causes the pleura to split open. Fre- 



i 



PATHOLOGY OF CARTILAGE INJURY AND DISLOCATIONS 335 

qiiently the lung is injured through being split by the trauma, even 
though the pleural cavity is normal. These complications lead to 
hemorrhage from the torn surfaces, or a collection of air in the pleural 
cavity from the outside atmosphere or the torn lung. When the two 
pleural surfaces are not adherent, hemorrhage may slowly fill the 
pleural cavity and cause death from lung collapse, anemia, or pressure 
on the thoracic viscera. Subcutaneous or surgical emphysema may 
also result from the pumping of air into the tissues from the lung direct, 
or from an external wound. If the lung is adherent to the parietal 
pleura by old adhesions, these complications are less likely to follow. 
The lung cannot collapse, pneumothorax has no opportunity to 
develop, and hemorrhage is circumscribed by the pressure of sur- 
rounding adherent tissues. Emphysema may be present with adherent 
pleura because the movements of the chest wall may force into the 
tissues air which has no means of exit and which is held by the valve- 
like closure of the wound edges during expiration. This may spread 
widely over the tissues of the body, involving the neck, face, and 
abdomen. With displacement after direct violence a fragment of 
bone may penetrate the lung and cause localized hemorrhage with 
hemoptysis, or localized pleuritis and lung consolidation. 

Occasionally the intercostal artery is ruptured in fracture in its 
course just below the rib. Hemorrhage from this artery is brisk and 
may pour itself into the pleural cavity or directly into the lung, and 
result in pulmonary hemorrhage via the bronchi. Other complica- 
tions are rare. The intercostal nerve may be pinched between frag- 
ments or caught in the callus. This causes pain from pressure neuritis, 
which lasts until the nerve has lost all function from continued com- 
pression. If one nerve alone is ruptured, there may be no area of 
anesthesia, on account of the overlapping of peripheral distribution 
of its neighbors. Empyema may follow fracture from infection of a 
hemorrhage into the pleura, or from direct infection from lacerated 
lung tissue. Osteomyelitis with necrosis of the rib may occur also 
from external or internal infectious sources. A lobar pneumonia may 
develop after rib injury. 

Paralytic ileus has been noted as another rare sequel. Adams^ 
reported 2 cases, 1 of which had no postmortem findings except 
rib fracture. The paralytic condition of the bowel probably results 
from irritation of the great splanchnic nerve which arises from the 
-ixth to the tenth thoracic ganglia near the heads of the ribs. Any 
retention of gas or fecal matter in the bowel favors the condition, 
so that the condition of bowel stasis shoukl receive early attention 
in treatment. 

Pathology of Cartilage Injury and Dislocations.— The pathology can 
be divided into: 

1 . Dislocation of the ribs on the verte})rie. 

2. Separation of the rib at its own costochondral junction. 

' Annals of Surg., li, 102. 



330 FRACTURES AND DISLOCATIONS OF THE RIBS 

3. Separation of the costochondral cartilage from the sternum. 

4. Fracture across the costochondral cartilage. 

5. Separation of one cartilage from another at a level below the sternum. 

1. Dislocation of the ribs on the vertebrae is found only in cases of 
extreme direct violence often associated with fracture of the trans- 
verse process of the vertebrse. If the transverse process is not broken, 
there must be laceration of all ligaments uniting the head and tubercle 
of the rib to the spine. The two lower ribs are the ones frequently 
dislocated, probably on account of lack of support anteriorly. The 
displacement is in any direction according to the force, and the kidney 
beneath may be bruised or lacerated by the trauma. The diagnosis 
is made by the finding of a break in the normal prominence of the ribs 
close to the vertebrae, the disappearance or undue prominence of the 
rib involved, and a lack of crepitus. The roentgenogram is essential 
to exact diagnosis. 

2. Separation of the rib at its own costochondral junction is the 
commonest form of thoracic injury occurring up to thirty-five years 
of age. There is no true joint here, and the binding ligaments are 
weaker than those at the sternal junction. The periosteum is torn by 
direct or indirect violence, and the cartilage displaced from the small 
notch by which it fits into the rib. The rib may overlap the cartilage 
in front or behind with distinct displacement, and several junctions 
may be damaged simultaneously. The diagnosis is not difficult, 
because there is distinct displacement and no fracture crepitus nor 
much swelling to obscure the findings. Pain may be annoying, and 
union may never occur; when it does it is bony. 

3. Separation of the costochondral cartilage from the sternum is 
more often a subluxation than a complete dislocation because of the 
complexity of the ligamentous attachments. It is commonly the result 
of indirect violence or muscular action in adolescents overstraining 
in physical competition or gymnasium work. The displacement may 
reduce itself, and the diagnosis is made on the constant point of 
tenderness, lameness affecting the chest or arm, and a thickening 
along the sternal margin. 

4. Fracture across the costochondral cartilage is usually transverse 
and is often overlooked. Displacement varies; one part lies in front 
of the other or no separation at all may exist. The diagnosis does not 
depend on symptoms in any way different from those of the foregoing 
classes, but is merely an anatomical one. Union is by bone. 

5. Separation of the cartilages from each other occurs in the group 
from the sixth to the tenth ribs which form the epigastric arch. This, 
a common injury, results from direct or indirect violence. Diagnosis 
is made on the persisting soreness to pressure or the movements of 
respiration. Coughing or sneezing are also painful. There is no 
crepitus, and the symptoms are located anteriorly. Deformity is 
rare. One rib may slip from the other on deep inspiration, with a 
click which is felt by the patient, and after healing a small mass may 
be palpable. 



COURSE AND PROGNOSIS 337 

Symptoms. — Fracture of one or possibly two ribs may give few 
symptoms. Pain in the chest, soreness, stitch in the side when sneezing 
or laughing are the common findings. After compression or a blow 
on the chest soreness is likely to he diffuse, and although detailed 
examination of the course of each rib is made, the surgeon may not 
be able to name the bones involved. Crepitus may sometimes be 
elicited by pressing on the sternum or spine, or it may be felt by the 
patient on deep inspiration. When the chest wall is thick and the 
soreness diff'use, it is unnecessary to cause distress by search for 
crepitus. If it is not readily made out by pressure in front and behind 
on the suspected rib, it may be felt by palpation with the palm on 
the chest wall, or heard by the stethoscope on deep inspiration. If 
several ribs are broken, the patient invariably assumes an attitude 
with body bent and head inclined toward the affected side to reduce 
the amount of motion in the chest. He may also hold the side with 
the corresponding hand. Deformity of the chest contour and a 
looseness of fragments are found only in severe and multiple fractures. 
After a day or two the point of tenderness to palpation or the pain of 
chest movement becomes more localized, and the patient can often 
put his finger on the spot of greatest distress. 

Pleuritic pain may appear secondarily. Hemoptysis may also be 
an early s^Tnptom, if any of the complicating causes are present. 
When this continues with pain, the surgeon must suspect that a 
fragment of bone has penetrated into the lung tissue. The symptoms 
of hemothorax, pneumothorax, and collapse of the lung are those of 
shock and air hunger and the chest findings on physical examination, 
which go with the respective conditions. Subcutaneous emphysema 
may start early and become alarming in its spread. The subcutaneous 
tissues become swollen and crackle on pressure. Respiration may 
be greatly embarrassed, and this complication may interfere with 
treatment and threaten life. Injury of the pericardial sack or the 
heart itself has been reported in rib fracture. In elderly people late 
complications may result which involve cardiac weakness and dilata- 
tion from long-continued pain and loss of sleep. 

Course and Prognosis. — Fracture of a single rib caused by direct 
violence has a painful course for the first week, followed by gradual 
relief and ultimate recovery in three to four weeks. If the patient 
keeps relatively quiet and has proper treatment, he may experience 
little sharp pain, unless there is pleurisy or chest movement from a 
reflex cough. If the patient desires to remain in bed, the most com- 
fortable position is a sitting one. Deep inspiration, sighing, laughing, 
and sneezing are to be avoided. After a week the pain decreases, and 
the patient can get about, but must avoid vigorous use or abduction 
and elevation of the arm on the affected side in dressing. Callus can 
nearly always be palpated and may lead to the complications men- 
tioned. Rarely several proximate rib ends may solidify together and 
form a bony mass in the chest wall, or a gap may develop through 
which a hernia of the pleura and lung appear. I have seen one such 
22 



338 FRACTURES AND DISLOCATIONS OF THE RIBS 

case, complicated by rupture of the diaphragm. The rib fractures 
were open, the diaphragm was sutured through their opening, and 
when the chest wall healed there was a large hernia of the lung out- 
ward beneath the skin scar. The complications alter the usual course 
because the fracture alone is secondary. Hemorrhage from an inter- 
costal artery, subcutaneous emphysema, pneumothorax, and pene- 
tration of the lung with hemoptysis may produce alarming symptoms 
and cause death. Generally emphysema disappears in a few days. 
Traumatic asphyxia following severe compression of the chest accom- 
panied by rib fracture is also a serious complication in the course. 
There is a marked cyanotic color of the skin of the face and chest 
and a capillary hemorrhage in the skin and beneath the conjunctivi^. 
The condition is caused by the traumatic intense passive congestion 
of the head and neck tissues with interstitial hemorrhages, which 
probably also involve the mucous surfaces of the respiratory tract. 
The blue color with dyspnea lasts for several days. 

In multiple fractures some permanent deformities of the chest con- 
tour persist. After dislocations and separations of cartilage and bone 
some deformity is the rule, but there is no pain, and function of the 
affected side is not much impaired. Arm movements may be impeded 
slightly. If non-union remains in cartilage fracture, the joint may 
slip out of place when the patient assumes certain positions, but it 
easily replaces itself and is painless. 

Treatment. — Simple fracture of one or two ribs requires relief of 
pain most prominently. Treatment must also look toward the cor- 
rection of displacements and the care of complications. To reduce 
the pain and to control chest movements which may result in pain 
or pleural irritation, the portion of the thorax involved in the fracture 
must be immobilized. If but one rib has been broken and it lies in 
the area of the prominent ribs which possess most movement, the 
lower two-thirds of the chest must be held quietly. Ordinary respira- 
tory motion may cause no distress, but sighing or laughing or an 
inadvertent deep breath cause sharp pain, as do also unexpected 
movements of the arm and trunk. Cough is also an every-day accom- 
paniment of rib injury, especially in elderly people with emphysema- 
tous chests and chronic bronchitis. For control of the pain strapping 
of the chest is indicated. 

Adhesive plaster is applied in a wide swathe extending from a point 
on the well side of the chest across the midline of the back, around 
under the arm to a point on the anterior surface beyond the midline 
of the sternum. This is tightly drawn into position while the patient 
makes a complete expiratory movement and holds the chest with the 
ribs relaxed as much as possible. An excellent position is one in which 
the patient stands with feet apart and well braced, the arm on the 
affected side abducted and the hand held toward the head. The sur- 
geon fastens the plaster in the back, the patient braces the feet, makes 
the deep expiration and the plaster is pulled as tightly around the 
injured side as it can be drawn and is made adherent on the front 



TREATMEXT OF FRACTURE OF THE RIBS 339 

surface under all the tension that can be applied. Relief from pain 
is immediate and lasting, because the unaffected side of the chest is 
left free for respiratory movements. The ribs on the affected side are 
relaxed into a normal position unless there is uncorrected overlapping 
and are held restricted so that inspiration fails to cause their move- 
ment and the pain which would follow the movement of the bone 
fragments with excursion of that side of the chest. The immobiliza- 
tion controls cough arising from reflex irritation from bone fragments 
or ruptured pleura, and if there is cough present from other causes, 
the strapping lessens its painful character by holding that side 
of the chest quiet. This treatment also fulfills requirements when 
there is hemoptysis caused by lung ulceration from bone fragments. 
It has always been my habit to use narrow strips of plaster one to 
one and a half inches wide applied successively in the manner of the 
swathe, each piece slightly overlapping its neighbor. If the seventh 
rib is broken, the first strip of plaster is applied in expiration well 
below the site of fracture with use of as much pressure as can be 
applied to hold the chest quiet. The plaster is put on without any 
wTinkles to make pockets on the sticky surface in which sweat may 
gather and cause skin maceration or infection. Each strip is added, 
building from below upward as high as necessary to overcome motion, 
and the finished dressing becomes one wide swathe when all is adherent. 
It has distinct advantages over a broad swathe, because there is press- 
ure in each width to hold the part immediately underlying, and the 
whole effect gives greater immobilization of the chest wall. The 
broad swathe has more or less of a uniform tension about the whole 
side of the chest and does not allow for the fact that the lower ribs 
can be compressed more because of greater elasticity. The strips 
must not be applied below the costal arch to pass over the epigastric 
area or to be fastened to it. This region must move in the move- 
ments of respiration, and if strapping is adherent to it, motion is 
transmitted to the chest. Fat persons are difficult to strap satisfac- 
torily, because the subcutaneous adipose tissue stretches and gives 
enough to lessen the tension of the plaster. This can be guarded 
against by carrying the plaster a little farther on to the well side both 
in the front and rear. Stout women or those whose breasts interfere 
with this treatment can be relieved by the use of two or three bands 
below the breast which run up in front between and leave the oppo- 
site breast free. The lower portion of the mammary gland can be 
held up and included in the strapping, but the edge generally cuts 
into the overhanging delicate skin and causes irritation within a few 
hours. The nipple should never be strapped over. The modern 
corset, which fits snugly about the lower ri})s and epigastrium and 
leaves the upper chest freedom of respiratory motion, is a useful 
adjunct in fracture of ribs in women. The corset may be drawn up 
tighter than usual and an aseptic pad of gauze or cotton can be laid 
over the injured area and then be held by the corset closing over it, 
much as a truss pad holds in a hernial protrusion. 



340 FRACTURES AND DISLOCATIONS OF THE RIBS 

When the fracture site is on the fourth rib or higher, strapping 
cannot give much reHef. The axilla prevents the application of 
a continuous compressing plaster dressing on the whole side. Chest 
movement may be restricted by bandaging of the arm to the side or 
by use of leather or light plaster-of-Paris forms which are strapped 
on over the opposite shoulder. Practically these are little used. 
The patient is kept quiet in bed or in a reclining chair, and a sedative 
cough mixture is given to control respiratory excursion. 

Strapping with adhesive plaster is contra-indicated when the skin 
is excoriated or abraded. I have seen removed from damaged skin 
plaster swathes which left behind a suppurating, eroded skin surface 
of large extent requiring weeks to heal over. The same condition 
may follow plaster left on too long or applied over dirty skin. Skin 
which has been cleaned with alcohol and carefully dried before appli- 
cation of the plaster will tolerate the dressing eight to twelve days 
with no great trouble. It should then be removed and reapplied if 
necessary. When pneumonia develops or respiration is embarrassed 
from pneumothorax or other conditions, adhesive strapping must 
be removed, and the pain caused by the fracture must be controlled 
by anodynes or local applications of cold. 

Reduction of displacement in fracture of the ribs is not of great 
importance, unless the displacement increases or is the cause of pain, 
or a bone fragment has penetrated the lung and caused damage or 
a surgical emphysema. Roentgen-ray study of injured chests proves 
that the ribs are often broken in two sites, when only one is clinically 
diagnosed. The portion of bone between the two fractures cannot 
readily be reduced and held in normal position on account of muscle 
stress. If several ribs are broken with an angular deformity, it is 
wise to attempt reduction of this before strapping. The shoulders 
are grasped and pulled backward by an assistant while the surgeon 
presses laterally on the displaced ribs with his flat hand, the patient 
being instructed to inspire deeply to force out the depressed frag- 
ments. This procedure may produce a successful reduction — or, 
more likely, the deformity recurs before the chest can be fixed firmly 
in the reduced position. Deformity in one or two ribs may be reduced 
by local pressure aided by the manipulation described, and a firmly 
applied strip of adhesive plaster applied at once in the rib axis often 
holds the reduction. 

The various dislocations are on the whole treated as fracture. 
Dislocations of the head of the rib on the vertebrae are not amenable 
to simple treatment, nor do they demand interference unless there 
is hemorrhage or nerve pressure. One can attempt reduction by 
having the patient cough or strain violently toward a position of 
flexion of the thoracic spine, the shoulders being elevated at the 
same time. The only direct reduction which can be made is by open 
operation, which is rarely called for, because non-reduction pro- 
duces no other trouble than some lameness in the muscles of the 
back. 



TREATMEXT OF FRACTURE OF THE RIBS 341 

Separation of one cartilage from another at the level below the 
sternum, or fracture across the cartilage does not lead to much deform- 
ity and is treated by strapping. If the deformity is great, manipu- 
lation with chest expansion and shoulder retraction will permit 
reduction. If these fail, resort must be had to operative treatment. 
Separation and dislocation of the rib from its cartilage or the carti- 
lage from the sternum is likely to give more displacement, if more 
than two ribs are involved. The same methods of chest expansion 
and manipulation should be used, and it is often better to leave a 
permanent deformity than it is to operate in that area. Displace- 
ment may be backward as well as forward and the rib ends in the 
epigastric region may sometimes be grasped in the fingers directly 
and reduction accomplished by traction and pressure. Results after 
healing without reduction are quite satisfactory, although the deform- 
ity is permanent and the chest is not strong enough for heavy work. 

Operative treatment and treatment of complications are nearly 
always synonymous. One seldom sees fractured ribs operated on to 
correct deformity. Dislocations, especially in the costochondral 
region, are sometimes corrected by open operation. If there is an 
open wound at the time of injury, the displacement should be cor- 
rected. Displacement outward at the site of fracture of one or more 
ribs can often be replaced by pressure. In patients who have fat 
thoracic walls the displacement may not be recognizable, and in 
muscular subjects the displacement returns at once. A small incision 
in the rib axis, which exposes the periosteum of the bone, may permit 
leverage of the fractured ends into alignment. Persisting overlapping 
may be cured by cutting oflP of a portion of the forward fragment and 
establishing realignment. If the pleura is torn, pneumothorax follows, 
which may cause more trouble than the original injury. As a matter 
of fact, operation is seldom performed. 

Hemorrhage from the intercostal vessels or the lung tissue is 
operable under some circumstances. It is difficult to diagnose the 
exact cause of the hemorrhage and in multiple fracture to determine 
the site. If there is an open wound and the intercostal hemorrhage 
is external, that vessel can be found by enlarging the wound. When 
the hemorrhage is internal into the pleural cavity or lung it may 
be concealed. There are two choices of treatment: one is to give 
morphia and keep as much blood in the extremities as possible by 
constrictions about the hips and shoulders, and the other is to cut 
down at a known site of fracture to find the bleeding vessel. Schiitte^ 
.states that the mortality of hemorrhage into the thoracic cavity is 
40 to 00 per cent, in untreated cases. In 12 cases of recorded opera- 
tion 9 patients recovered. 

The chest wall may be uncovered by a horseshoe incision with 
its base toward the sternum. The skin and superficial tissues are 
dissected back and the bleeding intercostal vessel is searched for 

' Munch. TTieri. Wchsrhr., June '.',(), 1908, p. 13SG. 



342 FRACTURES AND DISLOCATIONS OF THE RIBS 

and tied. If the hemorrhage comes from the lacerated lung, the ribs 
and parietal pleura are divided and turned back in a large flap toward 
the sternum. The lung is seized and the lacerations are sutured with 
catgut, after which the chest wall is closed by layer suture without 
drainage. 

Pneumothorax may demand aspiration of the air into a vacuum 
bottle. Late operations are indicated when the intercostal nerves 
are squeezed in callus or thoracic empyema or necrosis of a rib 
develops. These infections are treated by drainage or rib excision. 

Spreading surgical emphysema is treated by pressure bandages 
or adhesive strapping. If it becomes an impediment to respiration, 
multiple incisions through the skin and fascia are indicated to allow 
the escape of air. Generally the condition slowly subsides, and the 
air is absorbed after many days. When the crushing of the chest is 
severe and the subcutaneous emphysema develops rapidly, multiple 
openings do little good and often add to the shock. I have seldom 
seen severe cases of this character recover, not so much on account 
of the emphysema, perhaps, as on account of the accompanying 
injuries and shock. 



CHAPTER XIV. 

FRACTURES AND DISLOCATIONS OF THE HYOID BONE 

AND STERNUM. 

FRACTURES AND DISLOCATIONS OF THE HYOID BONE. 

These fractures are very rare. Gurlt collected 27 cases and Stimson 
has seen 3 cases. Most are associated with fracture of the thyroid 
and cricoid cartilages in the neck. They are caused by throttling, 
suicidal attempt at hanging, or direct violence of blows in the hyoid 
region. 

Anatomy. — This small bone lies between the tongue and larynx in 
close relation with each. By its muscular attachments to the tongue 
and th}Toid cartilage, it acts as the principal support of the tongue. 
It is also associated with all the movements of the larynx. The degree 
of looseness of the lateral thjTohyoid ligaments which unite the major 
cornu of the hyoid to the superior cornu of the thyroid cartilage has a 
bearing on dislocation of the major cornu. This ligament may be 
partly ossified in old age, and injuries of it may simulate fracture. 
Likewise, traumatic inflammation of the joint where it unites with the 
hyoid may s}Tnptomatically resemble fracture and dislocation. 

The site of fracture or dislocation is usually at the junction of the 
major cornu with the body of the bone, or, rarely, in direct violence, 
the body of the bone itself has been broken. The symptoms of frac- 
ture are acute pain and swelling in the region of the bone, accompanied 
by attacks of suffocation and dyspnea. There is pain in the throat 
when the patient attempts to talk or swallow. Swallowing may be 
impossible, and the tongue cannot be protruded. Crepitus, or a loose 
fragment, may be felt on manipulation. Complications exist because 
of rupture into the larynx or concomitant injuries of the trachea or 
thyroid cartilage. Isolated fracture or dislocation of the hyoid bone 
does not lead to subcutaneous emphysema, so that if this symptom 
is a prominent one, fracture of the thyroid and tracheal cartilages 
must be suspected. 

Dislocations of the major cornu are nearly as frequent as fracture; 
the pathology of the two is intermingled and the symptoms are similar. 
In all there are 11 cases on record, the last being added by Hazel- 
hurst.^ The literature of this condition was first mentioned by Olivier 
D'Angers.2 He stated that the dislocation was first described by. Val- 
salva, and on account of the prominent symptoms of dysphagia it 

» Johns Hopkins Hosp. Bull., 1912, xxiii, 344. 

* Diet, de Med., Paris, 1837, 7th ed., xvi, 105; and Bull, de Therap., Paris. 1830, x, 
01-93. 



344 FRACTURES AND DISLOCATIONS OF THE HYOID BONE 

was later called dysphagia valsalviana by Sauvage. The second and 
third cases were described by Mollinelli.^ In 1 case a young student 
had been assaulted and throttled by pressure on the right side of the 
neck. Other cases have been recorded by Mugna,^ Gibb, who saw 5 
cases in all,'^ and Ripley.^ Since that time Westmoreland/ Daly^ and 
Wood^ have added cases. 

These instances of dislocation of the major cornu have been of 
varying degree inward or outward and downward. The causes are 
choking or throttling pressure on the outside of the neck or pressure 
from within the neck by attempts to swallow large bodies, such as 
large pieces of meat. By direct violence the major cornu is displaced 
inward; its articular facet is pulled away from the corresponding face 
of the body of the bone. Violence from within the throat in swallow- 
ing causes a lateral and downward movement of the larynx, so that 
one of its horns impinges against the corresponding superior horn of 
the thyroid cartilage and remains there. One of Gibb's cases was 
examined at autopsy. The man had felt a sticking sensation in his 
throat which examination proved to be the displaced left major cornu 
of the hyoid. Dissection showed there was a pouch filled with clear 
fluid about the thyrohyoid articulation. This contained a large 
rhomboid-shaped, sesamoid bone, which had developed in the outer 
wall of this pouch. There was much motion in this joint. 

Of the 11 cases recorded, 2 gave evidence of local tuberculosis in 
the thyrohyoid articulation and larynx. None showed traumatic 
laryngeal changes. Three were in physicians. There was pain in 
swallowing in 6 cases and total inhibition of swallowing in 2 cases, 
4 showed anxiety and 3 had a feeling as of a foreign body blocking 
the throat. Voice and respiration may remain unchanged, in marked 
contrasts to the dysphagia. Four cases were reported caused by sudden 
movements of the jaws and neck in yawning, coughing, or singing, 
and the same number were caused by direct trauma of choking from 
without or from within by the ingestion of large masses of food. 

Reduction treatment has been successful in all the cases. This is 
done by gentle pressure or rubbing over the displaced part or by putting 
the anterior neck muscles on a stretch with the head held back. The 
jaw is then suddenly depressed, and the depressors of the hyoid bone 
pull it back into place. The same mechanism is accomplished by the 
attendant's making a firm grasp below the hyoid, having the patient 
swallow vigorously, and simultaneously giving a sharp, quick pressure 
on the displaced fragment, which produces reduction. If these methods 
fail, the surgeon's finger is inserted into the mouth at the side of the 

1 De Ossis Hyoidi luxationi, Bononiensi Sc. et art, Inst. Comment. Bononiae, 1767, 
V, Part 2, p. 106. 

2 Annali Universali di Med., November and December, 1828. 

3 Lancet, London, 1859, xxxii, i, 512. 

^ Hamilton, Fractures and Dislocations, 7th ed., p. 646. 

5 Tr. Med. Assn., Georgia, 1889, xl, 189, and Atlanta Med. and Surg. Jour., 1889-90, 
vi. 189. 

6 Arch. Laryngol. New York, 1880, i, 162. ^ Lancet, London, 1890, Ixviii, 68. 



FRACTURES AXD DISLOCATIOXS OF THE STERXUM 845 

tongue anterior to the tonsil which corresponds to the injury, and 
makes pressure downward and forward. The fingers of the other 
hand make a sUght pressure externally on the neck at the site of injury, 
and in some cases reported, the sliding back has occurred with a dis- 
tinct click. If the larynx has been punctured in fracture of the body 
or the respiration is seriously embarrassed by the displaced fragment 
or swelling, tracheotomy may be called for at once. 

There is immediate relief of symptoms after reduction. The con- 
dition is likely to recur. This was so in 6 of the 11 cases recorded. 
In Hazelhurst's case it had first occurred when the patient was seven 
years old. By the time he was twenty-three he was able to "set" 
the bone himself. 



FRACTURES AND DISLOCATIONS OF THE STERNUM. 

The sternum is composed of three parts, the manubrium, body or 
gladiolus, and the xiphoid process, the whole averaging six and a half 
inches in length. It is composed of cancellous bone like the bodies of 
the vertebrae, and has a thin cortex and a rich blood supply. The 
heaviest part of the bone is the manubrium, which rarely has osseous 
union with the body, a true diarthrodial joint often existing between 
them. The centres of ossification and the adult condition are illus- 
trated in Figs. 148 and 149. At the upper end this bone articulates 
with the clavicle and along the side of the body with the upper seven 
costal cartilages. Irregularities in development are met with, one 
form of longitudinal fissure leading to confusion with fracture. 

On account of the late union of the component parts, dislocation 
of the manubrium from the body is more frequent than true fracture, 
which is rarely seen before the third decade of life. If a bony union 
exists between the two upper parts, a true fracture is present when 
they are forcibly separated. Protection of the vital structures behind 
the sternum is furthered by the elasticity of the chest, contributed 
by the ribs on which the sternum rests. This elasticity, the cancellous 
structure of the bone, and its division into segments, make for the 
rarity of this injury. Satisfactory roentgenograms of the sternum 
cannot be obtained consistently, so that after injury it is impossible 
to tell whether bony or cartilaginous union or a true joint existed 
between separated fragments. Consequently fractures and disloca- 
tions furnishing similar clinical symptoms will be considered together. 

Occurrence. — In eight years at the Cook County Hospital in the 
series of 1 1 ,o()2 fractures the sternum was injured twelve times. The 
large majority of fractures are in males; there have been recorded 
cases of fracture of the bone in women during labor. 

Causes. — The causes of fractures of the sternum are direct and 
indirect violence and muscular action. Direct blows on the chest, as 
in car-V)umper accidents, compression injuries, accompanying frac- 
ture of the spine from hyperflexion, run over accidents and falls, are 
the usual etiology. Severe muscular exertion from contraction of 



346 FRACTURES AND DISLOCATIONS OF THE HYOID BONE 

the sternocleidomastoid and abdominal muscles in falls, or in women 
in labor, may separate the bone. Hamilton^ mentions a case related 
by IMalgaigne, of a mountebank who fractured his sternum when lean- 
ing backward to lift a weight. Violent coughing or sneezing may also 
dislocate the sternum, but the bone must be atrophic. Rib fracture 
may accompany the injury. 



Time 
' of 
appearance 




1 for manubrium 



-6th month 



4 for body 



1 for xiphoid 
process 



Fig. 148. — Ossification of the sternum. 



\7th month 
5 1st year after birth 



'5th to 18th 



year 



Pathology. — ^The line of the fracture is often transverse near the 
junction of the manubrium and the body or a dislocation diastasis 
of the joint. This is about the level of the second costal cartilage. 
Fracture may also be an incomplete crack or the tearing out of a shell 
of bone, as is found in dislocations of the sternal end of the clavicle, 



Time 

of 
union 




Rarely unite, except in old age 



Between puberty and the 25th year 



H V Soon after puberty 



6 Partly cartilaginous to advanced life 

Fig. 149. — Order of union of the various ossification centres of the sternum. 



or a costosternal junction. Multiple and comminuted fractures are 
caused by extreme violence, especially gun or cannon shots. Oblique 
and longitudinal fractures are very unusual and must not be confused 
with fissures of irregular development. Compound fractures other 



1 Fractures and Dislocations, sixth edition, p. 181. 



FRACTURES AND DISLOCATIONS OF THE STERNUM 347 

than those of gunshots are almost unknown, unless incidental to other 
fatal injuries in crushing accidents. 

The usual displacement in transverse fractures is of the lower frag- 
ment forward, with possible overriding (Fig. 150). Stimson states 
that there is but one true example of longitudinal fracture, in which 
one-half was depressed somewhat below the other half, reduction being 
made by abduction of the arm on the depressed side with pressure on 
the higher riding half of the bone. The periosteum is not always torn 
on both sm-faces of the sternum. Usually there is complete rupture 
in front, while the posterior layer is stripped up but retains continuity. 
This fact is important, because it saves the mediastinum from extrava- 
sation of blood. 

Other pathology deals with complications. There is one case 
recorded in which a fragment was driven through the skin by indirect 





Fig. 150. — Usual displacement in Fig. 151. — Types of sternal frac- 

transverse fractures of the sternum. tures found in the Warren Museum. 

(After Cotton.) (By Cotton.) 

violence. Injuries of the sublying thoracic viscera are common in 
gunshots, not in simple fracture. Rupture of the pericardium or of 
the heart itself has been reported. The costal cartilages or ribs may 
be fractured. Spicules of sternum or ribs may puncture the lung 
and cause emphysema of the tissue, pulmonary hemorrhage with 
hemoptysis, and severe cough or pneumonia. The mediastinal spaces 
and pleura are sometimes penetrated, and collections of blood which 
become infected from open wound or bacteremia result in abscess. 

Rupture of the posterior periosteal covering, or injury of the internal 
mammary vessels, result in hemorrhage which invades the anterior 
mediastinum. Immediate death from pressure on the heart or lungs 
may follow. 

Fractures of the manubrium are of two types: the usual transverse 
described in the pathology, and the splintered or sprain fractures 



348 FRACTURES AND DISLOCATIONS OF THE HYOID BONE 

accompanying dislocation of the contiguous structures. With these 
may be placed the dislocation of the manubrium from the body, the 
upper fragment being depressed behind the lower and the periosteal 
tear remaining anteriorly. The ca^^es of fracture during childbirth 
collected by Packard and Borland^ were practically all near the junc- 
tion of the two upper parts of the bone. If direct violence is the cause, 
there are usually fractures of the ribs or spine. 

Fractures of the sternal body are near the middle, at, or below the 
third interspace. The line of fracture is also transverse for the most 
part but may be oblique. The displacement is as of the manubrium, 
the lower fragment forward (Fig. 151). 

Fracture or dislocation of the ensiform process is very rare. This 
part seldom has bony union to the body of the sternum, and it cannot 
be fractured off except in aged people, and even in those cases it is 
doubtful if a permanent deformity would result. Hamilton records 
one case seen twelve years after accident in which the process pointed 
backward at a right angle and finally became symptomless. The 
elasticity of this small process permits bending, so that it tends to 
spring back into place when violently shoved out. I have seen two 
cases of loose xiphoid processes which were symptomless and probably 
followed traumata long forgotten. Persistent vomiting and dyspnea 
have been symptoms in some cases. The vomiting was probably 
caused by reflex disturbance of the peritoneum and pressure on the 
liver, like that found in small midline epigastric hernia rather than 
from any direct pressure on the stomach. Dyspnea is probably caused 
by pressure on the sternal fibers of the diaphragm. It seems impos- 
sible to believe that the phrenic nerves are pressed upon, as the 
displaced cartilage lies in the midline and below the level of the 
distribution of these nerves. A roentgenogram does not show an 
unossified cartilage. If a deformity persisted or gave symptoms, it 
could be reduced under anesthesia if necessary; if manipulation failed, 
open operation to replace or remove the fragment subchondrally 
should be performed. Diaphragmatic and epigastric hernia must be 
differentiated. 

Luxation of the ensiform process in a twenty-three-year-old man was 
reported by Skillern.^ The cause was a fall he suffered on a diving 
board six months before applying for treatment. He had pain in the 
epigastrium which was increased when he leaned forward. There was 
a depression present at the normal location of the process where the 
cartilage had been forced inward. 

Symptoms and Diagnosis. — If direct violence has been the cause, the 
patient may have been aware of something breaking in the front of 
the chest. There is pain, dyspnea, local tenderness, and, if any 
displacement, a deformity of the breast bone. Deep breathing or an 
erect posture are painful, the patient preferring to let the shoulders 
droop, and bend forward slightly, breathing with the lower ribs and 

1 Boston Med. and Surg. Journal, April 20, 1875. 

2 Internat. Clinic, Philadelphia, 1914, xxiv, S. 11, p. 238. 



FRACTURES AXD DISLOCATIONS OF THE STERNUM 349 

abdomen. The overlapping of fragments may be visible or palpable, 
unless there is great swelling. Deformity, crepitus, and mobility can 
be felt, or mobility of fragments may be observed during breathing. 
If hemorrhage forms beneath the skin, pointing forward, from a 
laceration of the anterior periosteum, the bone lesion may be disguised. 

Fracture or dislocation caused by severe injury with pulmonary 
or other complications may be overlooked, or the hemoptysis, emphy- 
sema, or thoracic hemorrhage may be alarming symptoms. Local 
tenderness or a delayed ecchymosis are reliable signs in sprain or 
crack fractures without displacement. 

Diagnosis must exclude contusion and congenital malformation or 
non-union of parts of the bone. Longitudinal fissures of the body, 
or seeming strange positions of the xiphoid which are congenital, must 
be considered. The Roentgen rays are of little value. Emphysema, 
hemorrhage, and other thoracic complications must be recognized, 
and accompanying injuries of the ribs and spine must be searched for. 

Course. — Simple fracture or dislocations heal readily and usually by 
a fibrous connection. Bony union in the fractures of the manubrium 
is often seen. Displacement may not be difficult to reduce, but it is 
difficult to maintain. The overlapping fragments and moving chest, 
which do not favor bony union, seem to have little bearing on the 
clinical result. Lltimate functional union is explained on the basis 
that one layer of the periosteum is usually intact. The character of 
union is unimportant; if there are no complications, a permanent 
deformity or a non-union do not result in difficult breathing or other 
interference with function. Abduction and adduction of the arms 
may be interfered with to a certain extent in bad deformity or non- 
union. 

Complicated cases with hemorrhage, emphysema, or with other 
accompanying injuries have a less favorable outlook. Lijuries of 
direct violence often lead to pneumonia, or complications, and shock 
may cause early death, the mortality averaging nearly 30 per cent. 
Infection of the hematoma, osteomyelitis, or mediastinal abscess are 
late complications which are serious. I have seen one abscess of the 
anterior mediastinum following months after fracture. The pus may 
burrow forward between the fragments or come out laterally along 
the sternum. A small sinus gives insufficient drainage, and the pro- 
cess may extend into the pleural cavity, pericardium, or lung. 

Open fracture and dislocation, especially injuries from gunshots, 
are to be classed with severe injuries. Hamilton^ quotes one which 
tore away the sternum and exposed the arch of the aorta. Complete 
recover\- followed. 

Treatment. — Simple fracture or dislocation which has reduced itself 
demands little treatment except rest. The patient is put in a half- 
sitting position, an ice-bag is placed on the chest, and every free- 
dom allowed the abdomen and lower ribs for respiratory purposes. 

' Fractures and Dislocatious, sixth edition, u. 184. 



350 FRACTURES AND DISLOCATIONS OF THE HYOID BONE 

If displacement is apparent and painful, causing crepitus and pain 
at each inspiration, attempts at reduction are made by extending the 
spine and drawing the shoulders back during deep inspiration. This 
pulls upward the upper fragment and the lower fragment, or its attached 
ribs can be pressed on, until the deformity is overcome. As previously 
mentioned, this deformity is very likely to recur. Strapping with 
adhesive is not strong enough to hold the reduction. A pad placed 
between the shoulder-blades and a figure-of-eight bandage holding 
the shoulders backward may maintain the reposition. 

If these methods fail, and the displacement causes no distressing 
symptoms, it may be left alone with little fear of complication. Objec- 
tionable deformity can be reduced by open operation. A convex 
incision along the outer border of the sternum permits the reflection 
of a flap down to the bone. A grooved director or periosteotome 
used also as a wedge may afford reduction when aided by pressure 
and traction. I do not know of any cases fixed by foreign bodies. 
The position after reduction must be maintained by the bandage or 
extension of the shoulders. 

Abscess and osteomyelitis in the sternum should be treated surgi- 
cally. Old deformities can be decreased by open operation by chiseling 
off of the new angle between the fragments. On the whole the simplest 
treatment is the best, and open operation will be rarely indicated. 
The complicated cases have a high mortality, and treatment is directed 
to saving life through combating those symptoms which threaten it. 
Operation for removal of fragments of bone to control hemorrhage or 
emphysema may be necessary. 

FRACTURE OF THE LARYNGEAL AND TRACHEAL 
CARTILAGES. 

The thyroid, cricoid, and tracheal cartilages are included. 

Fracture of the thyroid cartilage is rare and ominous. In crushing 
injuries of the chest and neck, thyroid cartilage fracture may be fre- 
quent, but on account of the urgency of other more apparent injuries, 
or early death, they may be overlooked. Lane^ mentions that out of 
100 cadavers examined he was able to demonstrate 5 with fracture 
of the laryngeal cartilages. 

The causes are direct violence from blows, falls across objects, hang- 
ing, and throttling. Muscular action may also become a cause in 
falls backward with the head hyperextended. . 

The mechanism of the fracture is pressure, exerted either laterally 
or directly backward against the vertebral column. Lateral pressure 
results in longitudinal fracture, particularly when the force has been 
applied on both sides of the neck. Multiple and comminuted fractures 
result from pressure backward. One cornu may be broken off by direct 
violence, as in a case reported by Stevens. ^ The man was struck by 

' Pathol. Soc. Trans., London, 1885, xxxvi, 825. 
2 Guy's Hosp. Reports, liv, 233. 



FRACTURE OF LARYNGEAL AND TRACHEAL CARTILAGES 351 

a fist while fighting, the right cornii of the hyoid was broken, and the 
superior left cornu of the thyroid cartilage was snapped off. The 
hyoid and inferior maxilla may be injured at the same time. Platt^ 
described a double fracture of the jaw together with fracture of the 
th\Toid cartilage in a fifty-eight-year-old man. There was a fatal 
termination in three days in spite of tracheotomy. 

Symptoms. — The symptoms are convulsive coughing, cyanosis, and 
usually a copious expectoration of fresh, frothy blood. Swallowing 
is painful, and the voice is affected in varying degree from hoarse- 
ness to complete aphonia. The serious cases, which are opened into 
the trachea by rupture of the mucous membrane, are characterized 
by a subcutaneous emphysema of the neck tissues. If there has been 
complete separation of cartilage fragments, there is abnormal motility 
and crepitus together with extreme tenderness when the parts are 
manipulated. 

Prognosis. — The prognosis is grave. Primary death follows from 
suffocation after an increasing dyspnea, emphysema or edema of the 
glottis. Delayed fatality is caused by pneumonia or hemorrhage. 
The mucous membrane of the larynx is always congested, and 
there may be a submucous extravasation of blood which spreads and 
involves the vocal cords. Matthews^ has reported a prompt recovery 
from cartilage fracture. I have had one case which was complicated 
by large subcutaneous emphysema and secondary hemorrhage on the 
fifth day and which recovered. The emphysema persisted twelve 
days. The repair in the cartilage is probably by scar tissue in most 
cases, but later ossification takes place. 

Treatment.— Treatment is symptomatic in most cases. The frag- 
ments can be returned to normal position by external manipulation, 
but if the symptoms of dyspnea are severe, an early tracheotomy is 
indicated. Attempts to reduce the fragments may start fresh hemor- 
rhage into the subcutaneous tissue, or the mucous membrane may 
be torn by manipulation. There is then danger of emphysema and 
hemorrhage into the lung. Uncomplicated injury is cared for by local 
applications of cold, a sitting posture, and sedatives to relieve cough 
and anxiety. Where the emphysema is the most prominent symptom, 
its spread may be limited by light pressure pads or multiple incisions 
through the tissues. Laryngeal examination is not always possible 
on account of the patient's condition. If the hemorrhage is severe 
and tracheotomy has to be performed, the bleeding can be controlled 
by a laryngeal tampon inserted above the tracheal opening. 

^ Manchester Med. Chronicle, December, 1S99, p. 108, 
2 .Jour. Amer. Med. Assn., Iv, No. 11, p. 943. 



CHAPTER XV. 
FRACTURE OF THE HUMERUS. 

Anatomy. — The humerus is built as a lever for motion at both ends, 
almost unlimited in direction at the upper end, and for anteroposterior 
hinge joint motion with the forearm bones at the lower. Of necessity 
it must be able to support weight between the trunk and loads in the 
hands and arms. For that purpose it is furnished with powerful, 
stout muscles which protect the head, hold it firmly to the glenoid, 
and guide these motions. For practical purposes two epiphyseal 
areas must be considered: the upper in the head just above the site 
of the anatomical neck at the attachment of the articular ligament; 
the lower in the trochlea just below the attachment of the capsular 
ligament at the elbow. The upper epiphysis is a fusion of three ossifi- 
cation centres, one each of the head, of the greater, and of the lesser 
tuberosity and unites with the shaft about the twentieth year. The 
lower epiphysis represents a similar fusion of centres. At the elbow 
the epiphyseal centre of the capitellum appears in the first six months 
of life, the epitrochlea and head of the radius in the sixth year, the 
trochlea and the olecranon in the eleventh year, and the epicondyle 
in the twelfth year. Study of roentgenograms taken as early as six 
months of age show the shadows of the olecranon and coronoid fossae, 
determining their position in the diaphysis. All these epiphyseal 
lines except that of the epitrochlea (internal epicondyle) have disap- 
peared at the age of fifteen years. The epitrochlea does not unite 
completely until the eighteenth year. 

The bone presents rather a thick compacta in its shaft and is almost 
triangular in section, whereas the head and lower end flatten out into 
a layer of compacta and closely meshed medulla of cancellous bone. 
At the extremities is strongly trussed cancellous bone, affording in the 
tuberosities and the condyles attachment for ligament, tendon, and 
muscle insertions. The lower end of the shaft of the humerus flattens 
out, narrowed in the anteroposterior direction and broadened laterally. 
The condyles form the lower extremity attached transversely to the 
anterior surface of the shaft and at a slightly oblique angle of 85 
degrees. This accounts for the deviation outward, away from the body, 
of the forearm, to form the carrying angle. Also as the condyles lie in 
the front of the shaft, the extent of motion is not equal on both sides 
of the extended longitudinal axis of the humerus, but is greater in 
the anterior arc (Fig. 152). The two condyles, external and internal, 
guard the depressions in the shaft at their base, the coronoid fossa 
in front, and the olecranon fossa behind, which fossa; are made to 



LIGAMEXTS AT ELBOW IX FRACTURE OF HUMERUS 353 

receive these tAvo processes of the uhia. The external condyle artic- 
ulates with the head of the radius by means of the capitellum, and 
the trochlea with its two lips allows hinge-joint motion between the 
internal condyle and the ulna. This motion would be present even in 
the absence of the radial head, limited by the lips of the trochlea, and, 
in case they were fractured, by the checking resistance of the lateral 
ligaments. The radial head besides articulating with the capitellum 
also rotate on its own axis in the movements of pronation and supina- 
tion of the forearm, as in the ball-and-socket joint, quite independent 
of other movements of the elbow. 

Above the two condyles are the bone tubercles for muscular attach- 
ment, the internal epicondyle (epitrochlea) on the inner side above 
the trochlea and the external epicondyle on the outer side. 






\\ 

\ \ 
\ \ 
\ \ 

\\ 



\ \ 

\ \ 

\ \ 
\ \ 

\ \ 



Fig. 1.52. — Diagram to show range of motion in elbow-joint. (Ashhurst.) 



Ligaments at the Elbow. — The joint capsule of the elbow is attached 
above the coronoid and olecranon fossae, blending with the periosteum 
of the humerus; on the inner side it is attached to the more prominent 
inner lip of the trochlea, so that the internal epicondyle lies without 
the joint. The external condyle and a very small portion of the exter- 
nal epicondyle are contained inside the attachment on the outer side. 
Below the joint the capsule is fastened to the ulna just below the ends 
of the olecranon and coronoid processes, and laterally along the margin 
of the greater sigmoid cavity of the ulna, and to the radius just below 
the orbicular ligament. Within the joint are the following structures: 
the coronoid, olecranon, and radial fossae, the whole trochlea, the 
external condxle and a small j)art of the external e})i('()ndyle, the 
articulating surfaces of the coronoid and olecranon processes, and 
the upper radio-ulnar joint, which forms a diverticuhim of the main 
elbow-joint. 
2.3 



354 



FRACTURE OF THE HUMERUS 



The c'a])siilar ligament is unimportant as a governor of elbow motion, 
except through the strong lateral ligaments. The internal lateral 
ligament passes from the internal epicondyle with the flexor muscles 
of the forearm to the inner surface of the olecranon and coronoid pro- 
cesses of the ulna; the external lateral ligament from the external 
epicondyle to the margin of the lesser sigmoid cavity of the ulna, 
spreading out around the radial head and blending with its orbicular 
ligament. Supporting the external lateral ligament is the supinator 
brevis muscle, which is firmly adherent to it. 

Ashhurst studied the limitation of motion in the elbow-joint.^ In 
fifty children of both sexes below fifteen years of age, he found that 

the average flexion equalled 31.1 degrees; 
the limit of extension averaged 187 degrees 
or 7 degrees beyond a straight angle (180 
degrees). This angle coincides with the 
hyperextension necessary to hold the arm 
at rest, when it is extended by the simple 
action of the ligaments. Further exten- 
sion is limited by the impingement of the 
tip of the olecranon process behind, against 
the humerus, and by tension on the anterior 
and lateral ligaments and the overlying 
brachialis anticus and biceps muscles. In 
this hyperextension the head of the radius 
remains in front of the axis of the humerus 
(see Fig. 153). 

If force in the direction of hyperexten- 
sion is applied, we have a mechanical 
problem arising similar to that arising 
at the wrist in falls on the hand. In 
children, whose ligaments and their inser- 
tions are relatively stronger than the bones 
in the juxta-epiphyseal areas, force of 
hyperextension causes a giving way of the 
lower end of the humerus. In adults, the 
bones being hardened and firm, the greatest 
stress falls on the anterior and anterolateral 
ligaments, especially on the inner side, causing them to rupture and 
permit a dislocation at the elbow. 

Examination, Measurements, and Aids. — Injuries about the shoulder- 
joint or upper arm can be investigated by help of several simple expe- 
dients. If a flat object, such as a ruler, is laid along the outer side of 
a normal arm in its longitudinal axis, this ruler will touch the external 
condyle, lie flat along the arm, and extend beyond the shoulder with- 
out touching the bony parts of the scapula. This helps to determine 
the axis of the humerus. In the normal arm the head can be made out 




Fig. 153. — Side view of bone 
of the arm in extension, showing 
the radius lying in front of the 
axis of the humerus. (Ash- 
hurst.) 



Fractures of the Elbow, 1910. p. 24. 



EXAMIXATION, MEASUREMENTS, AND AIDS 



355 



in the glenoid, and by placing the thumb or fingei- on the anterior 
aspect of the head and rotating the shaft, one can feel the tuberosity 
and head roll beneath the finger and thus establish their normal 
position and continuity with the shaft. Measurement of the points 





Fig. 154. — Illustration of the relative position of the bony points at the elbow in flexion 
and extension of the forearm. 

from the coracoid to the external condyle of the humerus will give 
practically the same distance in normal arms. Variation of not more 
than one-quarter or five-sixteenths of an inch is allowed for individual 





Fig. 155. — Illustrating location of bony points of the external condyle and radial head. 



error, difficulty in locah'zing bony points, and natural differences in 
length. 

When fractures of the lower end of the humerus and elbow are 
investigated, the bony points of that region must be compared with 



356 FRACTURE OF THE HUMERUS 

those of the normal arm. The external and internal condyles, joined 
by the intercondyloid line, should lie normally nearly on the level 
with the upper end of the olecranon with the forearm in extension. 
In flexion the two points of the condyles and the olecranon form an 
equilateral triangle. In addition, on the anterior aspect of the fore- 
arm just below the external condyle, lies the head of the radius (Figs. 
154 and 155), its rounded surface palpated best by a thumb or finger 
pressed here while the forearm is rotated. The position of the 
radial head does not vary regardless of the angle of the arm or fore- 
arm. If the ruler is laid down the back of the arm and extended 
beyond the elbow, it fails to touch the olecranon when the forearm 
is flexed. 

The carrying angle is the term applied to the angle made by the fore- 
arm in its attachment to the arm. In normal individuals this is about 
10 degrees outward away from the extended vertical axis of the arm. 
In fracture of the condyles or in the elbow neighborhood this angle 
may vary and become fixed, with corresponding loss of function. 
Because the carrying angle has much to do with the mechanism of 
elbow fractures, it should be correctly understood. Ashhurst^ also 
made a careful study of this angle in fifty children and found that 
the average angle was approximately 170 degrees. In girls the angle 
was an average of 2 degrees smaller (168 degrees) than in boys, 
a natural provision looking toward the broader pelvis in later life. 
As mentioned above, this angle is not caused entirely by the angu- 
larity of attachment of the forearm bones to the humerus, but 
is also caused by the slight obliquity of the surface of the humeral 
condyles. That is to say that the total angle of 170 degrees is not 
made up of a right-angled joint at the end of the forearm bones (90 
degrees) added to a chopped-off angle of 80 degrees at the lower end 
of the humerus. Each joint furnishes an angle of 85 degrees, making 
the total 170 degrees^ opening externally. This angle formation is 
of great importance from the standpoint of alignment of the arm and 
forearm, for on account of the equality of these two angles the fore- 
arm in extreme flexion is folded directly over onto the arm, and their 
axes correspond. Consequently in full flexion the forearm axis does 
not cross the arm axis, and the hand does not come to lie on the chest, 
if the carrying angle is maintained, unless the shaft of the humerus 
is rotated inward. The position of acute flexion holds the elbow-joint 
extremely rigid, as the strong lateral ligaments communicate motions 
of the forearm when it is used as a lever, directly to the humerus, 
and if a position of abduction or adduction of the forearm is main- 
tained while in acute flexion with a fracture of the humerus joint 
above the elbow, rotation of the lower humeral fragment will follow, 
and after healing a condition of cubitus varus or valgus will be fre- 
quent. Hence in fractures at the lower end of the humerus every effort 
should be made to maintain the normal position of the carrying angle, 

1 Loc. cit. 2 Potter, Jour, Anat. and Phys., 1895, xxix, 488. 



CLASSIFICATIOX OF FRACTURE OF THE HUMERUS 357 

and if the position of acute flexion is indicated in treatment as detailed 
later, the axis of the forearm should coincide with that of the arm and 
not fall to one side or the other. 

In the series of all racture cases at Cook County Hospital for seven 
years it is found that fracture of this bone occurred in 5.7 per cent, 
of the total number, a proportion a little higher than that given by 
other authors, who usually place fracture of the humerus at 4 per 
cent, of all fractures. 

Classification. — Fractures of the humerus are divided into those 
of the anatomical neck, surgical neck, greater and lesser tuberosities, 
and epiphyseal separations, of the shaft, supracondylar, dicondylar, 
condylar, and epicondylar. 

The mechanism of shoulder-joint injuries, including anterior dislo- 
cation, fracture of the surgical neck, fracture of the acromion, 
dislocation of the outer end of the clavicle, fracture of the clavicle 
and of the tuberosity of the humerus is similar. 

Hyperabduction and indirect violence are the causative factors 
in many shoulder injuries. They bear the same relation that forced 
dorsal flexion does to wrist injuries and lateral turns of the foot to 
ankle injuries 

Because of tension on the axillary part of the ciapsule, abduction 
of the arm is permissible to a degree only slightly more than a right 
angle, if the scapula is fixed. If the scapula is rotated in the abduc- 
tion movement, further abduction of the arm is possible, but when the 
limit is reached and the force acting continues, some part of the 
shoulder structures must give way; as in the wrist, either the capsule 
tears, or it pulls out of the bone surface if strong enough, or it remains 
entirely intact and the bone gives way. Thomas,^ and many others 
have demonstrated that the first structure to give way in hyperabduc- 
tion at the shoulder is the axillary portion of the capsule. As the 
action continues the tuberosity strikes against the acromion, and the 
head is forced out of the glenoid and the arm slides into a position of 
subcoracoid dislocation as it comes back again toward the body. 
Complete dislocation may not occur; laceration of the capsule, how- 
ever, may be present. Other lesions may accompany the condition; 
that is, other portions of the skeleton may give way, and fracture of 
the surgical neck would represent a breaking of the lever (the humerus) 
with or without capsular tear and dislocation. This fracture would 
take place in the lever just below the point of the fulcrum pressure, 
where the bone impinged on the acromion. Other possil)ilities are 
the giving way of the fulcrum itself (the acromion) attention to which 
has been called by Mencke.^ Fractures of the acromion not great in 
extent have been frequently found in shoulder dislocations. This 
fact woulfl tend to confirm the suspicion that they are caused by 
abduction through the mechanism just described. 

Another point in favor of a mechanism of hyperabduction lies in 

Jmir. Am. Med. Assn., Sopffrnhor 19, 1014. 2 Ann. of Sur^., lix, 2.^'{, 



358 FRACTURE OF THE HUMERUS 

strain on the greater tuberosity in instances of dislocation, either 
from tension by the capsular ligament or pull from the stretched 
spinati nuiscles, with resulting fracture of the greater tuberosity. 
These are frequent complications of dislocation, and the size of frag- 
ments varies from mere chips of bone when the ligament pulls out 
from its insertion, to large fragments when the insertions of the spinati 
muscles are also involved. The largest and best examples I have met 
with have bieen in subglenoid dislocations where the strain on the 
greater tuberosity is very strong. 

If the acromion, acting as fulcrum in this mechanism, holds, and 
some of the force exerted is transmitted along its supports, the clavicle 
enters the field of possible injury through its close supporting position. 
Its outer end, being poorly attached, may give; if that holds, the 
bone may be fractured at its middle or outer third, where it is thin 
and poorly protected; or its inner end may be forced out of position, 
causing a dislocation at the sternal end. Thomas^ reports 3 cases 
of upward dislocation of the outer end of the clavicle associated with 
anterior dislocation of the shoulder as evidence of a common mechan- 
ical cause, hyperabduction. The acromioclavicular joint is oblique 
from above downward and inward, and this angle favors the crowding 
against the clavicle by the acromion if it is pushed down. The liga- 
ments may be torn, some pieces of bone chipped off, or the joint 
injured, as has been shown by Sievers.^ 

Fractures of the Anatomical Neck.— Pathology. — ^The pathology of 
fractures of the anatomical neck varies (Figs. 156 to 160). The 
head may be completely detached from shaft and rotated about on its 
axis or even driven through the ruptured capsule into the axilla. 
Some of the periosteal attachment may persist, holding the head 
on the neck, or the force of injury may jam down the head and its 
soft cancellous bone on to the neck. Much blood is effused, and the 
joint capsule, if unbroken, is greatly distended, so that one finds 
much limitation of movement, severe pain at first, and crepitus, if 
the broken surfaces are unimpacted. 

Examination. — ^Measurement being taken from the bony point of 
the coracoid, which is found to be firm and painless, to the external 
condyle, shows, as a rule, no shortening of the arm. The axis of the 
humerus remains normal, and frequently there is a certain arc of 
passive movement which is painless and the patient can make some 
use of the arm, but function is impaired in direct relation to the force 
of the violence received and the displacement of fragments. Swell- 
ing may cause a simulation of a dislocation, but by Duga's test and 
the examination of the length of arm and humeral axis this can be 
differentiated. Duga's test consists in the surgeon placing the hand 
of the injured arm on the opposite shoulder and then pressing the 
elbow against the chest wall. If this can be done, no dislocation is 
present; if it cannot be done, dislocation is diagnosed. 

' Loc. cit. 2 Deutsch. Ztschr. f. Chir., cxxix, 583. 



FRACTURES OF ANATOMICAL XECK OF HUMERUS 359 

Firm pressure over the head, when the arm is grasped at the elbow 
and rotated, reveals a point of great tenderness and may elicit crepitus. 




Fig. 156. — Fracture of the ana- Fig. 157. — Fracture through the upper epi- 

tomical neck with rotation and physis and anatomical neck involving the 
impaction of the head fragment. greater tuberosity. Little separation. 




Fig. 158. — Fracture of the surgical neck and greater tuberosity with rotation and 
impaction of the upper fragments. This type of fracture leads to considerable restriction 
of motion in the shoulder if the fragments are not aligned and immobilized for a long 
period. 



360 



FRACTURE OF THE HUMERUS 



If inii)a('tion is suspected, as little manipulation as possible should be 
undertaken, that it may be preserved and the circulation in the head 




Fig. 159. — Fracture of the anatomical neck, loosening of the greater tuberosity and 
impaction with abduction of the lower fragment. 




Fig. 160. — Comminuted fracture of the head and greater tuberosity from direct 
violence. Note the formation of callus along the outer side of the bone where the perios- 
teum has been raised by a hematoma. 



maintained for nourishment. For a positive and complete diagnosis 
a skiagram is imperative. 

In impacted cases, or where the head is not widely separated or 



FRACTCRES OF AXATOMICAL NECK OF HUMERUS 361 

rotated, the callus arises largely from the lower fragment and may 
result in thickening of the neck, adherence to the capsule, and the 
formation of exostoses, if spicules extend out into the joint structure. 
In a large percentage of these cases considerable limitation of motion 
in the shoulder-joint results, especially in the direction of abduction 
and rotation outward. Where the healing process has occurred with- 
out immobilization and with irritation callus from use and motion, 
the axillary vessels and plexus branches are sometimes adherent to 
the mass at the neck. Non-union in these fractures may be caused 
by four dift'erent factors: (1) by insufficient immobilization; (2) 
by failure to bring the broken shaft into contact with the head, which 
by rotation may offer a smooth surface to the neck with interposition 
of periosteum or capsule; (3) by necrosis of the head; and (4) by 
the individual's failure to throw out callus. The old distinction 
of intra- or extracapsular is not so closely adhered to as formerly, 
and is of importance only as it concerns the blood supply of the head 
or the interposition of fragments of capsular ligament which prevent 
union. 

Treatment. — Treatment varies according to the amount of displace- 
ment. 

\Yhen the head is in fair position and impacted, support of the arm 
in a ^'elpeau or Desault sling is sufficient, with complete rest of the 
shoulder from four or five weeks to avoid excess callus from irritation. 
\Yhen they are painless, passive and active motion should be started 
and carried along in increasing amounts each day, but ahvays stopped 
short of pain. 

If there is no impaction and the position of the head can be satis- 
factorily determined, the shaft and neck should be swung out at such 
angle of abduction and rotation that they will meet the head, and this 
position should be maintained by a proper axillary pad. A shoulder 
cap of moulded leather or heavy cardboard, or a moulded plaster 
splint which extends up the entire arm on to the neck should be 
added. The axillary pad should be generous in size and not the usual 
small wadded-up bit of cotton. The Stromeyer cushion is the best. 
It is large, fits properly against the curve of the chest wall, is thick 
enough really to support the arm in abduction, and on account of its 
firm attachment to the chest will not slip down (Fig. 161). 

If the head is rotated clear around and its broken surface turned 
upward, the arm must be placed in extreme abduction and elevation, 
the patient being in bed with a weight of three to five pounds applied 
with plaster straps (Figs. 162 and 163). 

Formerly after non-union in this class of fracture, a common occur- 
rence, open operation was done, and the head, generally necrotic, was 
removed. If the upper fragment is detached long enough to become 
smoothed over, there is not enough left to freshen, and it must })e 
excised. Through early diagnosis and attempts at coaptation of the 
fragments many of these heads can be saved. When the head is 
removed, the neck becomes rounded oft', and the new shoulder joint 



362 



FRACTURE OF THE HUMERUS 



functions fairly well. Operation early, not after a wait of four weeks, 
as advised by Curtis,^ with pegging on of the head by means of ivory, 
bone or metal nails, gives best results. It may be necessary to open 
the joint capsule and to attach the head to the neck by kangaroo 
tendon with no other fixation. The arm is put up in an abducted 
position. In this operation a lateral exposure through the deltoid 
fibers can be made. 

Buchanan^ says that the entity of fracture through the anatomical 
neck with dislocation of the head fragment has been recognized for 
a hundred years, and yet there are but 34 undoubted cases on 
on record and 9 unverified cases. He added 1 case in which the 
head was dislocated below the glenoid and was removed by operation. 
The result was that active abduction was possible to 45 degrees, 
passive to 90 degrees, and swinging movements of the arm were good. 




< 



Fig. 161. — A cheap and easily made wooden splint for abducting the arm in ambulatory- 
patients. 

Of all cases of fracture dislocation on record up to 1908, 12 were not 
operated on, 3 had the head returned to the glenoid by open treat- 
ment, and 14 involved excision of the head. Six cases gave no clinical 
history. Malgaigne, in 1855, Bell and Spence, in 1863, and Bennett, 
in 1880, all believed that dislocation first occurred and that the sharp 
edge of the glenoid acted as a wedge against the head of the bone and 
sheared it off. This opinion was strengthened by the frequent finding 
in old dislocations of a groove in the head caused by pressure of the 
glenoid rim, about which more will be said under Dislocation of the 
Head of the Humerus. Shortly after Buchanan's paper, Mason^ collected 
63 cases of dislocation complicated by fracture of the neck of the 



1 Ann. of Surg., 1900, p. 291. 
3 Ibid., xlviii, 672. 



2 Ibid., xlvii, 659. 



FRACTURES OF ANATOMICAL NECK OF HUMERUS 363 

humerus, which he added to the 117 cases of ^IcBurney/ making 180 
in all. INIa son's collection showed 37 fractures of the surgical neck 




Fig. 162. — Fracture of the anatomical neck with extreme rotation and dislocation of 
the head fragment. Extensive capsular tear is expected. If reduction cannot be made 
by elevation and abduction of the arm, operation is indicated. 




Fig. 103. — Fracture of the neck extending down into the region of the surgical neck, 
iower fragment rotated inward and adducted. 



and 26 of the anatomical neck. The dislocations accompanying were 
divided into .suhcoracoid 31, subspinous 2, subglenoid 11, and 19 



.\nn. of Surg., 1894, v, 399. 



3(U FRACTURE OF THE HUMERUS 

not stated. ^lanipiilation was reported as successful in 7 cases, 3 
of which recurred, and as unsuccessful in 37. The treatment of the 
()i^ cases was arthrotomy and reduction in 23 instances, 14 of which 
(()(). 8 per cent.) gave good results. In 21 instances resection of the 
head was done, giving 9 fair results (43.8 per cent.). To allow the 
displaced head to become united in malposition to the neck and then 
to attempt reduction is a worthless procedure. Buchanan believes 
excision of the head is the operation of choice. He cites 14 cases 
from the literature, in which 2 results were excellent, 6 good, and 1 
moderately good. There were 2 deaths. The literature also con- 
tains a report by Syms^ of a man aged twenty-seven years, who sus- 
tained a fracture of the upper end of the humerus with dislocation of 
the head from the glenoid. The head was removed, the shaft replaced 
within the capsule, and motion started after the fourth week. In 
discussing the report) Gerster inquired why the head had not been 
nailed on in accordance with Murphy's advice. Nassau recorded a 
case operated on after a year of fracture dislocation in which the 
shoulder was ankylosed and much atrophy of the arm muscles was 
present. He used Kocher's posterior incision, resected the acromion, 
and took off three inches of the humerus, used early massage, and 
got a fine result. Miiller reports operation on a similar case, a female, 
aged sixty years, whose humerus he had fractured while attempting 
reduction of the dislocation. Functional result was good. 

Five cases are reported by Shands^ and Royster,^ in all of which 
the head was removed with but poor results except in one case. 
Downes^ reported a case in a four-year-old child in which all efforts 
to reduce failed, and at open operation a nail was driven in line of the 
head and shaft through the coraco-acromial ligament with the arm 
abducted 45 degrees. In three weeks the nail, which evidently pro- 
truded through the skin intentionally, was removed and the result was 
good. ]Mr. Robert Jones^ states that he has roentgenograms of over 
40 cases of fracture dislocation. When manipulation fails he extends 
the arm perpendicularly and manipulates the head into position. 

Old cases with restricted motion do not promise well. To expose 
the field, an anterior incision with severance of the tendon of the 
pectoralis major muscle about three-eighths of an inch from its inser- 
tion is the best. This is the same approach used in old dislocations 
of the head of the humerus.'' At the bottom of this opening one can 
identify the axillary vessels and plexus; if they are adherent to the 
torn capsule or callus, they can be carefully freed by sight with dis- 
secting done close to the bone and the neck cleaned of its excess callus. 
The head is either removed or straightened, and by a suturing of the 
pectoraHs muscle with mattress stitches to its tendinous insertion the 

' Ann. of Surg., Iviii, 574. 

2 Am. Jour. Orthop. Surg., viii, 389. 

•■' Jour. Am. Med. Assn., August 10, 1907. 

4 Ann. of Surg., Ivii, 282. 

^ Pror. Roy. Soo. Med., December, 1910. 

/' Andrews, Surg., Gynec. and Obst., i, .385. 



FRACTURES OF SURGICAL NECK OF HUMERUS 365 

wound can be closed except for a capillary drain at the lower end. 
Capsulotomy should not be overlooked as an aid in allowing freedom 
of motion. If parts of the capsule are removed or if it is opened widely, 
regeneration quickly follows. Good results after open operation on 
old cases are rare on account of the long-standing pathology and the 
patient's unwillingness to attempt and repeat motion after operation. 
Compared to final results after attempts to break up adhesions under 
anesthesia there is much to be said in favor of open operation, and 
the risk of tearing important axillary structures is far less when the 
open work is done. If the head is shoved down into the axilla or the 
case is an old one which on axillary palpation reveals a large bony 
mass and has much restriction of motion, operative interference is 
indicated. If impaction has occurred, this should be preserved, unless 
the head is in very bad position of rotation on its axis, so that when 
healed it will interfere with shoulder motion or become adherent in 
a detrimental manner to the other important structures. These cases 
are much better treated by open operation than by blind attempts 
to manipulate the head into position on the neck. 

Kocher's posterior incision to expose the shoulder-joint starts in 
front at the acromioclavicular joint, runs down over the acromion 
and scapular spine, and then curves toward the lateral aspect of the 
chest. The acromioclavicular joint is exposed, and after the acromion 
is drilled for the wire to hold it later, it is separated by a saw. The 
deltoid fibers are laid outward, the joint capsule being thus exposed. 
The anterior approach given previously has the advantages that no 
bone has to be cut into, and that the important structures, nerves 
and vessels, are in sight and can be avoided. In the posterior methods 
these lie beyond and in front of the head of the bone, deep in the 
wound. 

Fractures of the Surgical Neck.— These may be oblique, transverse, 
or serrated, with large, jointed fragments either in the front or back, 
usually in front. The bone breaks below the tuberosities to which the 
muscles are attached, and hence the head is somewhat rotated and 
abducted. This injury results from direct violence or severe indirect 
violence and torsion on the arm or elbow with the muscles above in 
tense contraction. The shaft is drawn inward by muscular attachment 
of the pectoralis and teres major and latissimus dorsi, while the biceps, 
coracobrachialis, and deltoid draw it up (Figs. 164 and 165). 

The vessels or nerves in the arm may be seriously injured, and 
examination shows shortening of the arm. The head lies in the glenoid ; 
the shoulder is not flattened, but there is a depression below where 
the shaft joins, unless there is great extravasation of blood. The 
axis of the shaft is directed inward, and the elbow -is out from the 
body. Passive rotation of the arm with the surgeon's finger at the 
neck of the humerus gives distinct crci)itus and is very painful, and 
the head does not move with the shaft unless it is impacte'd (Figs. 16(), 
167, and 168). 

Shortening up to one and a half inches \ aries with the (h'splaccment. 



366 



FRACTURE OF THE HUMERUS 



If the fracture is impacted much less shortening, no crepitus, and not 
much change in the humeral axis is expected. If there is impaction 
and the fragments are well wedged together, immobilization in a 




Fig. 1G4. — Fracture of the surgical neck; impacted head fragment abducted. 




1 



Fig. 165. — Fracture of surgical neck of the humerus., The shaft fragment is abducted 
and rotated in by the attached muscles. 

sling and shoulder cap, with axillary pad or coaptation splints may 
be sufficient treatment. If much shortening or overriding is present, 
attempts at reduction can be made with the danger to the brachial 



FliACTURE:S OF SURGICAL NECK OF HUMERUS 



367 





Fig. 166. — Healed fracture of the surgical 
neck. Xote the large amount of callus, the 
angular deformity, and the ease with which ab- 
duction of the arm would be restricted. 



Fig. 167.— Fracture of the 
surgical neck in a child. There 
is impaction, splitting and ab- 
duction of the upper fragment. 




Fig. 108.- 



- fracture of the surgical neck with the greater tuberosity remaining attached 
to the head fragment. Shaft drawn inward. 



308 



FRACTURE OF THE HUMERUS 



vessels and nerves in mind. The Middledorpf triangle is an excellent 
dressing', if good reduction can be made. 

When adjustment of the fragments is not satisfactory and anes- 
thesia is contra-indicated or open operation is refused, treatment by 
continuous traction with a weight will give good results in some 
cases. Extension is made by adhesive strips applied along the anterior 
and posterior surface of the arm from the shoulder to the elbow (see 
Fig. 169). The hanging of a weight of five or ten pounds on this will 




Fig. 160. — Treatment of fracture of the surgical neck by continuous traction. The 
triangular portion of the wooden splint is attached lightly to the chest and the arm cannot 
slide down into the box regardless of the position the patient assumes. 



allow the patient to be up and about; or he can be kept in bed. When 
in bed, extension is lost unless applied with the patient on his back. 
If the head fragment is rotated badly and the shaft has to be placed 
in extreme abduction and elevation to meet it, the patient must be kept 
in bed, extension applied over the whole length of the arm, and weight 
hung on. The general rule is for the attendant to bring the shaft, 
over which he has control, in line with the upper fragment, devising 
such means of holding that position as each case warrants (Fig. 170). 
These fractures lead frequently to non-union and must be given five 



FRACTURES OF SURGICAL NECK OF HUMERUS 



369 



or six weeks for healing. A large callus is the rule, and frequently cir- 
culatory and nervous disturbances of the arm are late complications. 
When callus has appeared after three weeks, the arm can be taken 
out of its dressing daily and carefully massaged for its circulatory 
good. When union is firm and use is started, to obtain free shoulder 
motion, the patient should be instructed to carry weights with the 
arm and should try each day to abduct and elevate the arm a little 
more, resting it against a door or wall and using the body weight to 
force abduction. If the fragments cannot be brought into apposition 
and maintained there by these means, plating or pegging by intra- 
medullary bone splint driven up into the head should be considered. 




Fig. 



170. — P>acture just below the surgical neck. Note the angularity and apparent 
shortening of the arm. 



Brickener^ suggests a method of slow, continuous abduction traction 
for shoulder disabilities and limited function. The patient lies in bed 
well supported by pillows. The arm on the affected side is abducted 
as far as it can be comfortably and is then fastened to the head of the 
bed by a muslin bandage about the wrist. The head of the bed is 
elevated on blocks, and as the patient's body gradually slides down, 
the arm becomes more abducted and elevated. This position is 
acquired painlessly and gradually as a rule, and is merely a manner 
of forcing abduction when the patient will not take active exercises 
for that purpose. It may require a week's time to obtain a full result. 



Medical Record, New York, Ixxxvii. No. 1, 



24 



370 



FRACTURE OF THE HUMERUS 



It* the traction becomes irksome or painful, it may be loosened for 
awhile or applied only at night. 




Fig. 171. — Postoperative picture after application of a plate for fracture of the 
surgical neck. A loose middle fragment has been included under the plate. Skin clips 
indicate skin incision. 




Fig. 172. — Plated surgical neck fracture. It was necessary to use a nail to attach the 
separated greater tuberosity. 

Open operation for plating or intramedullary splinting in this 
region gives excellent results. Care must be taken of the circumflex 



FRACTURES OF SURGICAL NECK OF HUMERUS 



371 



nerve. Usually no matter how dovetailed the fragments are they can 
be fitted perfectly together. After-dressing consists in a IVIiddledorpf 
triangle or a moulded plaster applied gutter fashion on the lateral 
side of the arm, with the forearm in flexion and midway between pro- 
nation and supination. This allows the arm to be in a comfortable 
position and in abduction to favor the replacement of fragments. 

The prognosis, as a rule, is good. There may persist some shortening 
or limitation of shoulder movement, but the scapula makes up for 
much of this, and the function should be good. Many weeks of per- 
sistent attempts at use, with massage, are necessary before a final 




Fig. 173.— Surgical neck fracture be- 
fore reduction. Note displacement and 
shaft rotation. 



Fig. 174. — Operative reduction of the 
preceding fracture. The picture seems to 
be of the other arm, one from the nega- 
tive, the other from the print. 



stage is reached, and in children even the most unpromising cases 
may function very well in later years. Operative cases should receive 
particular attention in regard to after-treatment, that they may 
secure an earlier good result and a^'oid muscular atrophy about the 
upper arm. 

Separation of the upper epiphysis occurs in chiklren and young 
adults as a result of direct violence or in combination with indirect 
violence. Displacement is of varying degree. The line of separation 
follows the epiphyseal line closely, leaving the head and tuberosities 
in the upper fragment. In this fragment is a concavity, and the k)wer 
fragment is convex on the end so that the displacement is in many 



372 FRACTURE OF THE HUMERUS 

instances limited to slight separation with no lateral movement. 
When indirect violence is combined in the cause, the shaft is generally 
so impacted that on examination the head may rotate with the shaft. 
There may be little crepitus on account of the soft character of the 
bone at this site, and the whole neck feels full with a prominence on 
the forward and inner aspect of the shoulder. The head is felt in the 
glenoid and other signs of dislocation are lacking. 

The treatment of this condition is most important. If the head is 
not replaced, it may become necrotic, and will certainly interfere with 
growth. This epiphysis unites last and is the most important area 
in growth of the arm; it should he replaced in every instance. This 
may be accomplished by manipulation with the arm in abduction and 
rotation to meet the physical findings and the evidence furnished by 
the skiagram. Subsequent care is as given for fracture of the neck, 
with complete immobilization for four weeks and partial for three 
weeks more. In the partial period passive motion and massage with- 
out pain are indicated. 

A series of 11 cases of injuries of the upper end of the humerus, 
which simulated birth palsies, was reviewed by Peltesohn.^ Five of 
these were true Erb's palsy, and 6 showed bone injury of the upper 
epiphysis of the humerus. A typical case of false birth palsy showed 
a rigid shoulder- joint, some inward rotation of the arm, and inability 
to raise the arm above an angle of 90 degrees. In most cases the arm 
was held in abduction of 30 to 50 degrees, and although there was no 
true paralysis, there was paresis of the shoulder-girdle muscles. The 
cases of true palsies showed no contractures and had free front and 
side movements, but there was true muscular paralysis and atrophy of 
the pectoralis major and shoulder-girdle muscles. The diagnosis is 
made by roentgenogram. Peltesohn suggests that both shoulders 
must be taken for comparison, the position, of the arms being main- 
tained in the same degree of rotation, and the exposure must be 
instantaneous that movement may be eliminated. Examination of 
the roentgenogram demonstrates either a change in direction of the 
humeral axis or an abnormal distance between the end of the diaphysis 
and the clavicle. The whole epiphysis may be displaced outward. 

In cases which have healed with displacement and deformity there 
is usually found a prominence of the enlarged epiphysis below the 
spine of the scapula. These old cases are treated by open osteotomy 
and correction of the axis of the lower humeral portion so that it makes 
alignment with the upper piece. Fresh cases in younger children are 
treated by elevation, abduction, and outward rotation of the arm. 

If the head cannot be reduced or the reduction allows spicules or 
one edge to project over the shaft, open operation should be done, the 
head positively replaced, and any excess or projecting bone chiseled 
away. After this, one may hope for continued growth of the humerus 
and as little limitation in movement as possible. As little manipula- 

1 Berlin Klin. Wchnschr., June 22, 1914, p. 1162. 



FRACTURES OF SURGICAL KECK OF HUMERUS 



373 



tion of the epiphyseal area as will reduce the displacement is indicated. 
Rough handling of the surfaces with instruments is not indicated; 
a narrow chisel blade cautiously inserted between the head and neck 
will be foiuid of use as a lever to efi'ect replacement of the soft bone. 
Simple replacement is usually sufRcient, the arm being dressed in 
position to favor this. Foreign bodies except absorbable sutures are 
better left out. 

Fractiu-e of the greater and lesser tuberosities is not as uncommon 
as believed. It occurs from direct violence or more frequently from 
muscular action and indirect violence as detafled in the mechanism 
of shoulder injuries. Direct violence, a blow or kick on the shoulder, 
or a fall on the upper arm may act. 




Fig. 175. 



-A slight frat;ture of the tuberosity caused by a pulling out from muscular 
action. 



Muscular action, pulling out the tuberosity, occurs usually under 
one of three conditions: (a) In dislocation of the humerus; (b) with 
fracture of the neck; (c) with fracture dislocation (Figs. 175, 176, 
and 177). 

The fracture is either complete or partial; the latter is more com- 
mon. Careful skiagrams in anterior dislocation will reveal parts of 
the tuberosities pulled off in a surprising number of cases. At the 
Cook County Hospital I find an average of 15 a year. In 1907 
Keene searched the different hospitals in Philadelphia and found 
23 cases; among skiagrams for shoulder injuries Mason^ found 21 in 
the literature complicating dislocation. Gibbons^ reports a case from 
muscular violence alone, and Taylor^ reports a case of fall on the 



1 Loc. cit. 



2 British Med. .Jour., 1909. 



' Ann. of Surg., xlvii, 10. 



374 



FRACTURE OF THE HUMERUS 



shoulder with no dislocation, in which there was an isolated fracture 
of the greater tuberosity. In the period before the introduction of 




Fk;, 176.^ — Ununited fracture of the tuberosity of ten months' standing. The greater 
separation was probably presented by some holding areas of periosteum. 

Roentgen rays Gurlt (Knochenbriichen) collected 46 cases from all 
sources, all but 2 of which were associated with other injuries, generally 
dislocation. Thirty cases were recorded by Melchior in eight years. ^ 




Fig. 177. — A more extensive pulling out of the tuberosity by muscular action and direct 

violence. 



The most complete separation of the greater tuberosity occurs in 
su})glenoid dislocation, on account of the attachment of the infra- 



1 Beitr. z. klin. Chir., Ixxv, 184. 



FRACTURES OF SURGICAL NECK OF HUMERUS 



375 



and siipraspinati muscles. In anterior dislocation the subscapularis 
may pull out the lesser tuberosity (Figs. 178, 179, and 180). 




Fig. 178.— Subglenoid dislocation. Note the abducted position of the arm and the wide 
detachment of the fractured tuberosity. 




Fig. 179. — The same patient after reduction of the dislocation, the tuberosity is .still 

displaced. 



376 



FRACTURE OF THE HUMERUS 



Study of the pathology reveals, pulled out from the head, the shell 
of bone, as large as one and a half by one inch, leaving behind it a 
sulcus in the cancellous portion of the head. The fragment is pulled 
upward and inward, and if skiagram is made before reduction of the 
dislocation in cases of that etiology, the displaced fragments can easily 
be distinguished at some distance from the head. In some instances 
this plaque of bone is comminuted, but is held together by its perios- 
teum and muscle insertions. Failure in replacement leads to excess 
callus beneath the fragment, involving the spinati muscles, limiting 
movements of outward rotation, and by impingement against the 
glenoid rim above limiting abduction and elevation. When the separa- 







r 
r 

r 



Fig. 180. — Operative repair of the fractured tuberosity showu in the two preceding 

pictures. 



tion is not wide, but is complete, bony union may never take place, 
and a pseudarthrosis develops beneath the fragment, with disability 
in the motions mentioned. In cases of lesser degree union follows, 
as a rule, and the ultimate result is satisfactory, if the arm is immob- 
ilized long enough. Many cases are totally unrecognized. Ecchy- 
mosis is usually absent. Arm movement is limited to an unusual 
degree, more than is expected after simple dislocation, and while 
adduction may be normal or increased, abduction and outward rota- 
tion are very poor. Passive abduction is also limited, either by pain 
or by a wedging in of the fragment between the head and acromion, 
which locks the joint on movement attempted beyond a certain posi- 



FRACTURES OF SURGICAL NECK OF HUMERUS 377 

tion. If separation is but partial, the disability is not so great, but the 
recovery is prolonged, and there is permanent loss of function. That 
the fragment may be shown well, the roentgenogram should be made 
with the arm adducted and rotated outward, so that the shadow of 
the tuberosity stands out clearly. 

Diagnosis is difficult without the Roentgen rays. When dislocations 
are reduced and pain and tenderness on the outer side of the head of 
the humerus persists unduly, and function is not normally estab- 
lished, this fractm-e should be suspected. In cases of extreme separa- 
tion after reduction of dislocation, by bringing the arm in abduction 
and rotating with the thumb pushing down on the tuberosity, one 
can feel a crepitus and establish an acute point of tenderness. When 
complicated by fracture of the neck, roentgenogram alone will establish 
diagnosis. 

Differential diagnosis mugt cover subdeltoid and subacromial 
bursitis, fracture of the anatomical neck, periarthritis, deltoid and 
circumflex paralysis, and in old cases, fracture of the glenoid. A guarded 
prognosis must be given in contusions of the shoulder which do not 
rapidly clear up, unless a good roentgenogram proves that no frac- 
ture exists. 

Treatment by attempted reduction, with arm swung up over the 
head in abduction and maintained there, is the only method except 
open operation. To maintain the arm in this position for three weeks 
in order to allow bony union, with no positive information that the 
fragment is in place, is not very satisfactory. The surest and shortest 
method is for the surgeon to make an incision through the deltoid 
fibers on the lateral aspect of the shoulder, find the loosened and 
retracted tuberosity, fit it on the grooved area of the head, and insert 
a small nail or screw. Where the fractiu-e is comminuted, two or more 
pegs may be needed. The arm should then be dressed in abduction 
with a moulded plaster splint from the chest wall up to the wrist, 
well padded throughout. Ten days in this position followed by a 
gradual letting down gives satisfactory results, with no excess callus 
and good shoulder movement. To operate on these cases and main- 
tain the operative technic is difficult, but practice enables one to 
feel quite well by means of a blunt-pointed hemostat without putting 
fingers into the wound, and this operation can be done through a small 
incision. It seems unnecessary to add that w^hen a fracture of the 
tuberosity is a complication of dislocation this latter should first be 
reduced, the fracture operation following. Phemister^ advises opera- 
tive approach from the rear by Kocher's method. He reports a case 
in which the fragment was fastened on by wire, and in w^hich an 
examination of a loose piece removed showed its entire fracture sur- 
face covered with callus thicker than that over the periosteal and 
tendinous covered area. This finding would naturally be expected 
(Fig. 181). 

» ' Ann. of Surg., September, 1912, p. 441. 



378 



FRACTURE OF THE HUMERUS 



Fracture of the upper end of the humerus compHcated by disloca- 
tions is not very common. It is caused either by a continuance of the 



<5/f/n edge 




1 



Fig. 181. — Operative repair of fractured humeral tuberosity by nailing. The skin clips 
indicate the skin and incision length. 




Fig. 182. — Fracture of the upper end of the humerus with dislocation of the head frag- 
ment which is turned completely out of the glenoid until the tuberosity points inward. 

incHrect force of the dislocation, which acts after the head has been 
forced out of the glenoid through the capsule and breaks the l:fone 



FRACTURES OF THE SHAFT 379 

iu the region of the neck, or by cUrect violence. Such accidents 
may be a combination of dhect violence received on the shoulder 
simultaneoush' with or after indirect violence causing dislocation 
(Fig. 1:S2_). 

The displacement is usually complete, with the edges broken 
obliquely or serrated well up into the neck, and accompanying injuries 
to the nerves and vessels. Hemorrhage causes great and early swelling 
and masks the conditions on examination. No crepitus at all may be 
found. The arm is of usual length or slightly shortened, the axis of 
the humerus, that of dislocation, and the deltoid area flattened with 
its fibers under tension. The head may be palpated out of the glenoid, 
and muscular action, drawing the upper end of the shaft forward and 
inward, may cause an opening to the air from within outward. In 
severe injuries in this region with great swelling, this condition should 
be borne in mind, and before the performing of rough manipulation 
the possibility of harm to the vessels and nerves should be thought 
of. A skiagram should be had in every case possible and the posi- 
tion of the fragments carefully studied before attempts at reduction. 
Stereoscopic plates are of assistance. 

Treatment should be under complete anesthesia. Attempts at 
reduction are made, first to get the head into the glenoid, and then 
to get the shaft in line, as in fracture of the neck. If ill-advised treat- 
ment is instituted with incomplete diagnosis, and the reduction of 
the dislocation is tried, great damage to the axillary structures may 
be done, especially if after failure by the Kocher method the stockinged 
foot is placed in the axilla and much force used in extension. Should 
the condition of the skin warrant, and permission have been obtained 
before anesthesia for open operation in case of failure of manipula- 
tion, this type of fracture should be operated at once to avoid com- 
plications. It is necessary to get the bone in proper place and hold 
it by silver wire, kangaroo tendon, or ivory peg. If much comminu- 
tion exists, and there are loose fragments, they should be removed 
and apposition obtained by trimming of the large fragments before 
fixing with the means used. If these cases are not so treated, the 
head may become necrotic, callus may cause damage to nerves or 
vessels, and frequently a false joint develops about the upper end of 
the shaft which leads to a flail joint. Should the head be completely 
broken, it is best removed and the trimmed upper end of the shaft 
introduced into the glenoid, the neighboring muscles attached to it 
by bronze aluminum wire. After such reposition a new head may 
develop, and if the muscles are firmly attached, new tuberosities also 
appear, so that the ultimate function may be very gratifying. Great 
dangers are sepsis and nerve injury. 

Fractures of the Shaft. — These occur at any point in its continuity 
and are caused by direct or indirect violence, torsion, and muscular 
action, as in throwing weights or balls, wrestHng, sudden apphcation 
of heavy force on the forearm and hand with the arm muscles tense. 
Twice the author has seen subcutaneous tearing of the biceps muscle 



380 



FRACTURE OF THE HUMERUS 



caused by sudden strain of heavy force on the hand, the brachialis 
anticus muscle and insertion holding, the humerus withstanding the 
strain, and the biceps giving (Figs. 183 and 184). 

Pathology. — The pathology is varied. The line of fracture may be 
oblique, transverse, dovetailed from before back, or from the sides 
aud splintered, with a separate piece of the shaft loosened. Impaction 
is rare. According to the site of the fracture and its character dis- 
placement varies. If the site is above the insertion of the deltoid 
muscle, the upper fragment is drawn inward by the pectoralis major 
and the lower fragment upward and outward by the deltoid; when 
below the deltoid insertion, the upper fragment is drawn outward, 
the lower one inward and upward and always with rotation of from 
15 to 90 degrees (Figs. 185 and 186). 




Fig. 183. — A transverse fracture of 
the humerus. There was a greater over- 
riding present than is shown in the 
roentgenogram. 



Fig. 184. — Repair of the preceding by a 
plate, a full length of arm obtained. 



The examination reveals obvious fracture. The arm is shortened, 
a false point of motion evident, loss of function complete, and crepitus 
present. When the muscles are lacerated and a piece is drawn between 
the fragments, upon rotation no crepitus will be felt. As the fracture 
site approaches the elbow the displacement becomes anteroposterior, 
the lower fragment is drawn forward by the muscles extending to the 
forearm, and a splitting of the bone down toward the elbow-joint is 
common. Injuries of the great vessels are rare. x4s a complication, 
injury to the radial nerve in its course around the bone is the most 
common. It must be recalled that for over three inches of the lower 
half of the bone, this nerve twists around the shaft, so closely connected 



FRACTURES OF THE SHAFT 



381 



with it that a sulcus is formed in the bone for its pathway and it is 
not imbedded in the soft tissues. Although this arrangement would 
seem to offer many chances for a catching of the nerve between frag- 
ments, the accident is really rare. Fracture at any point in this 
contact may unfortunately tear the nerve or contuse it so that its 
impulse-conducting power is temporarily abolished, or when the 
fracture heals, the nerve sheath may become entangled in the callus 
and when ossification follows, the nerve is pressed and its function 





P'lG. 185. — Severely comminuted spiral frac- 
ture of the humerus. The head fragment is 
drawn up and out by the deltoid, etc. Note the 
rotation of the shaft. 



Fig. 186. — A combined spiral 
and oblique fracture of the shaft. 
The lower break involved the radial 



ruined. Scudder and Paul, in 1185 cases of fractured humerus, report 
the musculospiral nerve injured eighty-six times. 

This complication occurs chiefly in fracture of the middle third, 
next in the lower third, and least often in the upper third. Von Bruns's 
collection of 886 cases in 1886 showed 53 per cent, in the shaft, 22.2 
per cent, in the proximal end, and 24.7 per cent, in the distal end. 
The later figures of Kiethus^ show 33.6 per cent, in the shaft, 35.4 
per cent, in the proximal end, and 31 per cent, in the distal end in 319 



Beitr. z. klin. Chir., Tubingen, xxiv, 703. 



;m> fracture of the humerus 

cases of fractured humerus, of which 4.1 per cent, were compUcated 
by musculospiral paralysis. Some instances of motor paralysis are 
not accompanied by a corresponding loss of sensation over the dis- 
tribution of this nerve, a state of affairs which may be explained by 
the fact that the sensory supply to the radial half of the dorsum of 
the hand leaves the nerve above the usual point of involvement in 
fracture. Any age is liable to this injury. Vennat^ reports 13 cases 
in children, in 3 of which there was complete division of the nerve. 

Depending on time of appearance, the cases of paralysis are (a) 
primary, in which the nerve is damaged by the injury causing the 
fracture, or by the bone fragments themselves and (6) secondary, 
occurring during the healing process, from compression or stretching 
by the callus, or subsequent to healing from bone infection or pseud- 
arthrosis. Loss of power in the forearm extensors may be partial or 
complete and follow immediately after the fracture or during the 
healing. Some degree of anesthesia, most marked on the dorsum of 
the hand between the metacarpal of the thumb and first finger, is the 
usual finding. The fingers assume a position of flexion at the meta- 
carpophalangeal joint, with slight flexion and ulnar abduction of the 
wrist. The thumb is adducted and the forearm pronated. Should 
the sensory paralysis be extensive and follow the injury at once, 
rupture of the nerve above the middle of the humerus is probable. 

In the secondary cases the callus begins to interfere with the nerve 
after the second week. Tinglings and sharp pains begin, and a slow 
functional failure develops, so that it is important at the early 
examination after fracture to ascertain that this nerve is intact. The 
sensory and motor disturbances begin simultaneously and atrophy or 
trophic changes are rare. 

Prognosis. — Prognosis depends on the treatment and the length 
of time after injury that it is instituted. There are instances on 
record of recovery when operation was done as late as three and a, 
half years after the onset. The improvement may follow within a 
few days after operation if the cause has been of secondary character, 
or may be delayed as long as a year, and Riethus^ records 1 case 
of two years' duration. When there is both motor and sensory 
disturbance, sensation returns. If electrical reaction of complete 
degeneration is present, the outlook is more unfavorable. 

Indication for operation is absolute in complete severance of the 
nerve, although there is no immediate pathognomonic symptoms 
so that many cases, especially of the primary type, are treated expec- 
tantly, until time shows no improvement. Von Bruns recommends 
operation if there is no improvement after four to six months. Many 
of the primary cases recover without operation. As the secondary 
type of paralysis does not occur spontaneously, it should be operated 
upon early, especially if the roentgenogram shows malposition of the 
bones and large callus. This early release of the nerve reduces the 

^ Monograph, Lyons, 1900. 
2 Loc. cit. 



FRACTURES OF THE SHAFT 383 

degenerative changes to a minimum and stops further progress of the 
paralysis. Scudder and Paul believe that all doubtful cases should 
he subjected to operation; that is, primary cases which improve and 
then suffer a recurrence during callus formation, or cases with an 
increasing paralysis, should be considered secondary cases. Stationary 
partial paralysis with partial reaction of degeneration may recover 
without operation. In the primary cases if one can be assured of 
continuity of the nerve, restoration of function will surely follow. 

Treatment.^Treatment consists in freeing the nerve from adhesions 
or callus, resecting it if a scar has formed in its continuity, or it is so 
pinched that the axis-cylinders within may be crushed beyond recovery, 
and suturing the freshened nerve ends, with fine linen. It is rarely 
necessary to resect a portion of the shaft of the humerus to accomplish 
apposition of the nerve ends, and it is best not to disturb the bone 
at the time of the nerve operation for fear of causing further callus 
formation. The freed or sutured nerve should be supplied with a 
proper bed of fat taken from the immediate field or from the thigh 
or abdomen if absolutely necessary. The fat should be rolled around 
the nerve as a thick pad for a distance of an inch and a half on each 
side of the site of injury. At the Massachusetts General Hospital 
the end-results were obtained in 11 cases, 8 of which had no wrist- 
drop and 3 had no improvement, although 1 of these 3 was poerated 
on twice, the bone shortened by resection, and the bulbosu nerve 
shortened and resected. The longest interval before improvement 
was three years 

Treatment of Shaft Fractures. — A favorite and efficient early dressing 
is a loosely applied coaptation splint on the padded arm. Care 
is taken to get the fragments in the best position by manipulation. 
This can readily be done without anesthesia. The forearm is 
steadied in a position of flexion, extension is made from the elbow, 
and by gentle rotation the shaft can be brought into line, the fingers 
of one hand guiding the fragments at the site of fracture. The 
-plints should be carefully watched to avoid interference with 
circulation as evidenced by numbness and tingling in the hand 
and forearm, cyanosis and swelling of the hand, loss of capillary 
pulse in the nails or the radial at the wrist. The splint should 
be removed within a few hours after first application for inspection 
and to allow for the first swelling. These dressings may be supple- 
mented by the Middledorpf triangle, which may also be used- alone. 
If coaptation splints of padded wood or metal are used, or a moulded 
plaster splint, the forearm should be at a right angle, midway between 
pronation and supination, with the wrist suspended by a suitable 
sling from the neck. In applying such a sling the attendant may use 
either a folded broad piece of muslin or a broad bandage, taking a 
couple of turns about the wrist and fastening at the back of the neck. 
Knots at the back of the neck should be avoided, as they cause pain 
from pressure, and by pinning or by padding the neck the little irrita- 
tion of bandage tension can be done away with. If moulded plaster 



384 



FRACTURE OF THE HUMERUS 



is used, and it is an excellent dressing, two pieces may be applied, one 
on the outer and one on the inner aspect of the arm from the shoulder 
and axilla to the wrist. These are bandaged on or fastened by adhesive. 
The author never uses a circular cast on fractures of the upper extrem- 
ity; much damage has been done by them, to say nothing of their 
disagreeable weight. Volkmann's ischemic contraction may follow 
these fractures, and reference should be made to the paragraph on this 
in the section on General Pathology. If reaction is normal, union will 
be complete in five or six weeks, and thereafter the arm is carried in 
a simple sling for a short time; massage and motion follow, and a 
total disability of three months gives a useful arm (Figs. 187, 188, 
189, and 190). 





Fig. 187. — Spiral fracture of the 
humeral shaft. Note the rotation of 
fragments. 



Fig. 188. — Operative repair of the 
preceding. Practically perfect appo- 
sition and correction of rotation. 



The shaft of the humerus permits of relatively easy operative 
approach, and as this bone is the sole support in the arm and many 
cases of non- or malunion result from its fracture, open operation 
is frequently done on it. Incision is made on the outer aspect of the 
arm to avoid the nerves and vessels on the inner side. The bone is 
cut down and exposed with care to avoid the radial nerve if operat- 
ing is being done at its level. In opening a series of these cases one is 
struck by the great displacement and rotation not evidenced in the 
skiagram, and in cases favorable for operation there results a perfect 
anatomical joining which other treatment cannot give. It is under- 
stood, however, that even in poorly treated cases, after years of work 
and use, nature makes a good bone, as shown by many specimens in 



FRACTURES OF THE SHAFT 



385 



museums, in which ahgnment is good and calhis absorption so great 
that little permanent evidence of the fracture remains. To get a 
quick, good joining, operation promises a sure return. If the fracture 
is serrated or oblique and reduction cannot be maintained, operation 
will give a shorter convalescence and a normally long arm. Applica- 
tion of the Lane plate is very satisfactory here, as in the shaft of the 
femur. Wiring is not done as much as formerly in shaft of this bone, 
but bone pegging with an intramedullary splint from the tibia has 
an advantage over plating in cases not too oblique, in that no foreign 
material is implanted. 





Fig. 189. — Transverse fracture of the shaft 
of the humerus by compression. 



Fig. 190. — Operative repair of the preced- 
ing by an intramedullary splint. 



As the humerus is the lone bone of the arm, when the fracture is 
open, the ends can readily be turned out (Figs. 191 and 192). The 
bone peg is inserted in the medullary cavity of one fragment after 
slight curettement, and then by manipulation it is snapped into the 
other end and the rotation corrected with almost perfect approxi- 
mation and much firmness. A moulded splint is carefully applied 
over the closed skin in such a manner that the incision can be exposed 
and stitches removed without disturbance of splint or arm. Healing 
follows with a minimum of callus formation and a short convalescence. 
25 



386 



FRACTURE OF THE HUMERUS 



I'nunited fractures of the shaft occur. These are caused at times 
by constitutional disturbances, as mentioned in the general remarks 
and locally by the following factors: First, and most important, 
the arm is not properly immobilized nor for long enough time. The 
elbow should be immobilized with the arm, and the splint should 




Fig. 191. — Operative repair of a very long spiral fracture of the humerus by means of 
an intramedullary peg. The plane of the fracture separation, extended much higher 
than the roentgenogram, shows and the bone peg was cut very long to give stability. 



extend to the wrist. Coaptation splints used alone about the arm 
are likely to cause this condition, as the forearm frequently is left 
quite free and causes motion at the site of fracture by its movements. 
Second, the fragments are not brought into good position and callus 
formation is hindered. Third, fragments of periosteum or torn muscle 
find their way between the fragments at the time of fracture and are 



FRACTURES OF THE SHAFT 



387 



not removed. Compound fracture, especially those produced by gun- 
shots, are frequent causes of non-union. To apply dressings, to allow 
drainage, or to avoid pressure of splints in this class of cases leaves 
little immobilization, and if infection occurs or pieces of muscle get 
between fragments, non-union is apt to follow. In gunshots, when 
the humerus is shattered, chance for early bony union is less than in 
the forearm or leg, where a companion bone offers support as a splint. 
When failure of union develops, and the arm is swung in use, there 
appears after a few months a well-defined pseudarthrosis. If the 




Fui. 192. — Healed wound of intramedullary transplant shown in the preceding picture. 
Xote the alignment of the arm. 



fracture has been a transverse or oblique affair, a capsular ligament 
forms around the broken end (Figs. 193 and 194), and a new smooth 
lining with free fluid develops. If the fracture has been comminuted, 
this new false joint may not be so well defined, but its structure is 
the same, and in cases operated, its dissection involves much work and 
time. One case here illustrated required an hour for the freeing of 
the sack of the joint, as the radial nerve ran down in its wall and on 
the inner side it was adherent to the sheath of the great vessels (see 
Figs. 195 and UMij. 
Treatment of ununited fracture in the humerus is purely operative. 



388 



FRACTURE OF THE HUMERUS 



Boring or drilling the ends is of no value, for as indicated above, the 
lining of the false joint must be completely removed to prevent recur- 
rence. This false joint is carefully taken out by slow, sharp dissection 
and the ends of the bone sawed off to open the medullary cavity 
which has been sealed over by the joint surface to bring fresh 





Fig, 193. — Ununited fracture 
of the humerus of nineteen years' 
duration. Note the rounded and 
eburnated ends and the closed 
medullary cavity. 



Fig. 194. — Ununited fracture of the humerus 
of a year's duration. This was completely cured 
by an intramedullary transplant of bone. See 
photograph. 



bone surface in contact with fresh surface that union may be stimu- 
lated. If in doing this there is lost some length of the arm, an undesir- 
able condition, the full distance can be maintained by cutting the bone 
transplant so large that it will have to be driven into the medullary 
cavity with a little force, and then the ends of the fragments can be 
separated to hold the former length, the intramedullary splint sus- 



FRACTURES OF THE SHAFT 



389 



taining them apart and yet in alignment. Rarely this condition has to 
be supplemented by a peg driven through the shaft of the fragments 
to hold the intramedullary splint in place, but if care is taken to cut 
it large enough this will not happen. Bone or ivory pegs are better 
for this purpose than metal, which may lead to irritation and demand 
removal (Figs. 200, 201, and 202). 




1 




V 



Fro. 195. — Ununited gunshot 
frar-ture of the humerus of seven 
years' duration. The dark masses 
are lead. 



Fio. 196. — Repair of the preceding by 
Lane plate. It was found impossible to use 
either an inlay or intramedullary bone graft 
on account of the comminution of the lower 
fragment and its thinness. 



A Lane plate is not indicated in this type of fracture, and much time 
and annoyance can be saved the patient by not attempting to plate 
but to u.se the intramedullary splint in the first instance. The plate 
does not hold firmly enough and will not allow for shortening caused 
by resection of the bone ends, as with a plate the fragments must be 
brought into apposition. 

After intramedullary splinting, in closing the wound, care must 
be taken to maintain the position until the skin is sutured and the 



390 



FRACTURE OF THE HUMERUS 




Fig. 197.— Ununited fracture of the humerus. The scars of the original open fracture 

can be seen. 




Fk;. 198. — Presentation of the false joint in the arm when it is abducted. 



FRACTURES OF THE SHAFT 



391 



arm firmly splinted from the neck to the wrist. This splint should 
be left on about six weeks, depending on the osteogenetic reaction 
and then a lighter moulded sphnt on the outer surface applied for 




Fig. 199. — Ununited fracture shaft following gunshot seven years ago. Standing 
at rest scars on arm can be seen but no deformity to be noticed. When he attempted 
to raise arm the part above the non-union came up but that below hangs down helplessly 
as dead weight. No nerve involvement, as shown in the pictures of voluntary extension 
and flexion of hand and fingers, supporting weight of arm on other hand. 




Fig. 200. 



■Ununited fracture of the humerus just above the elbow from an old open 
fracture. 



302 



FRACTURE OF THE HUMERUS 




4 



I*'k!. 201. — The false joint of the preceding picture was repaired by an intranieduHary 
splint (Ryan.) Note the alignment and flexing of the arm. 




Fic. 202. — Same, showing extension of the arm. This man came into my service seven 
months later on account of a fracture of the tibia through the site from which the intra- 
medullary splint was taken. 



four weeks more. After this, if bony union is inaugurated, the arm 
can be kept in a shng for a couple of months and be svipplied with daily 
massage and passive motion. These cases are very stubborn, and if 
the operation is undertaken to cure them, no effort or extra precaution 
of asepsis or immobilization must be spared in the after-treatment. 
Success should not be promised, of course, and the patient should 
understand the length of the postoperative care, but if the indication 
for each point in the technic is complied with, failure will rarely 
follow. 





Via. 203. — Mechanism of fracture of 
external condyle from fall on hand. (.\sh- 
hurst.) 



Fio. 204. — Fracture of the humeral 
shaft with forward displacement of the 
lower fragment. 



General Mechanism of Fractures of the Lower End of Humerus. — 

1. Falls on outstretched hand are the usual cause. The chief force 
is transmitted by the radius, through the carpus — the ulna does not 
articulate with carpal bones. Force is transmitted via the radius to 
the external condyle of humerus via head of bone and capitellum. For 
this force to reach the internal condyle it must first be transmitted 
to the ulna. This is accomplished by means of the interosseous liga- 
ment, the fibers of which pass obliquely downward from radius to 
ulna and act as a shock absorber (Fig. 203). If they passed in this 
direction from the ulna to the radius, such distribution of force would 
not follow. Hence falls on the hand lead to fractures of the external 



304 FRACTURE OF THE HUMERUS 

condyle, or because the anterior and lateral ligaments hold and make 
the elbow -joint rigid, the humerus is broken above the joint trans- 
versely. Sudden hyperextension at the elbow produces transverse 
fracture of the humerus from the binding of the ligaments. If these 
ligaments are to be torn, it can only be accomplished by slow, powerful 
extension, and dislocation results. 

As most displacements in the transverse fractures of the lower end 
of the humerus are of the lower fragment backward (Fig. 204), it is 
reasonable to suppose that the cause is not a simple thrust transmitted 
by the radius and ulna, for the condyles are set fonvard on the end of 
the humeral diaphysis and would naturally tend to be displaced for- 
ward. If hyperextension is acknowledged as the cause of these frac- 
tures, the transmission of the violence by the strong ligaments as 
described carries the lower fragment of the humerus backward. We 
know that these fractures are not caused by fall on the hand with 
the forearm flexed at a right angle, and that muscular power is not 
sufficient to hold the forearm flexed in such a fall, so that the mechanism 
by hyperextension as outlined is the usual one. 

If we recall the anatomy of the carrying angle and its opening out- 
ward, we see that in falls on the extended hand the major portion of 
the strain falls on the internal lateral ligament, which, although 
stronger than the external ligament, is more frequently ruptured. 
The carrying angle also is a factor in fracture of the external condyle 
by direct compression through the radius. 

2. Violence received in falls on the flexed forearm, or with the elbow 
in flexion, by driving the ulna against the trochlea, may fracture off 
the inner condyle of the humerus or cause olecranon fracture and 
anterior dislocation of the radius. Falls on the flexed forearm with 
the impact received on both forearm bones causes transverse fracture 
of the lower end of the humerus or epiphyseal separation. When 
the point of impact is on the acutely flexed elbow, if the arm is slightly 
abducted the blow falls on the internal condyle, which will be broken, 
and if the arm is held close to the body, the outer condyle suffers 
in a similar manner. Should supracondylar fracture result from fall on 
the flexed elbow, the fragment of the humerus can be carried forward 
by the ulna into the bend of the elbow, as described by Posadas. 
Fracture of the olecranon or radial head frequently accompanies this 
injury (Figs. 205 and 206). 

3. Force applied on the outer side of the extended arm at the elbow 
in a fall to the ground with the extended arm beneath the body usually 
causes forced adduction of the forearm, pulling off the external condyle 
by action of the external lateral ligament or leading to ■ comminuted 
supracondylar fracture. 

Examination of Elbow-joint.— If examination is not made immediately 
after injury, several days may have passed in treatment by lotions 
or external applications. Swelling gradually subsides, and the elbow 
is useless, stiff, and painful and may not even be cared for by a sling. 
Inquiry into the history of the accident may reveal the type and 



MECHAXISM OF FRACTURES OF EXD OF HUMERUS 395 

direction of trauma received, but in many instances, particularly in 
children, no definite information can be secured. Both the sound 
and injured arms should be compared, and the patient should be 
asked to move the injured elbow actively, if it is possible for him to 
do so. Usually the elbow is held stiffly, and the whole arm moves as 
a unit from the shoulder alone. Inspection may also reveal the deform- 
ity, the swelling, and ecchymosis, if more than twenty-four hours 
have passed since injury. 

Palpation must determine if possible the location of the bony points, 
and it is wise first to examine the uninjured elbow in order to become 





Fig. 20.5. — Transverse 
fracture of the lower end of 
the humeral shaft. 



Fig. 206. — Healed repair of the preceding 
fracture. The alignment is good and the callus 
is not excessive. 



familiar with the normal and to gain the patient's confidence. With 
the finger tips the subcutaneous border of the ulna can be traced 
throughout its whole length, including the olecranon. Then the 
radius can be palpated, its head recognized, its rotation with the 
shaft determined, and the position of the external condyle established. 
With these two points settled it is not difficult to find the more promi- 
nent internal condyle and to prove the other relations of the bony 
points compared to the normal. When these points are in normal 
position dislocation can be excluded, but not fracture; while if the 
points are abnormal, fracture, dislocation, or both may be present. 



396 



FRACTURE OF THE HUMERUS 



Careful palpation of the shaft of the humerus from above downward 
lielps to determine the character of the injury and the position of 
fragments. Ashhurst advises also immediate tests for paralysis or 
anesthesia of the ulnar, radial, and median nerves. 

Crepitus and a false point of motion can be detected by holding the 
arm (luuiierus) in one hand, the forearm in the other, and using gentle 
flexion and extension, then following by forward and backward or 
lateral rocking of the forearm held at a right angle. In supracondylar 
fracture the lower fragment of the humerus moves with the forearm. 
Crepitus may be found. To determine the loss of continuity in the 
humerus, the surgeon grasps the flexed forearm and uses it as a lever 
to rotate the humerus, to determine the movement of the diaphysis 




Fig. 207. — Recent supracondylar fracture of the humerus. Note the apparent back- 
ward displacement of the lower fragment, the injury of the soft parts, and the patient's 
desire to hold the forearm flexed. 



with the lower part, pressing a finger over the head at the shoulder, 
as in examination of the shoulder injuries. If no positive findings 
result, the condyles themselves can be grasped and manipulated by 
being rubbed together for demonstration of tenderness, crepitus, or 
false motion. If there is motion between them, and neither is attached 
to the shaft, intercondylar fracture can be diagnosed. The manipula- 
tions should not be rough; if the examination is systematic and gentle, 
little pain will result and no damage will be done, and fewer fractures 
will go undetected on account of impaction or poor examination. 
Anesthesia may be indicated for diagnostic examination, but the 
Roentgen rays are surer and less troublesome. 

Supracondylar fracture, through the broad part of the shaft a couple 
of inches above the joint, is frequent and often followed by much 



MECHAXISM OF FRACTURES OF END OF HUMERUS 397 

restriction of function. Causes are: falls on the hand or forearm with 
the forearm flexed, or direct violence received on the arm above the 
elbow. In practice at the County Hospital, Chicago, where the 
police bring injured malefactors, it is found that "gunmen," or the 




Fig. 208 



Fig. 210 



Fig. 208. — A very delicate complete supracondylar fracture in a child. Careful study 
of the roentgenogram demonstrates the complete plane of separation. The periosteum 
has been torn on both sides. This is not a green-stick fracture. 

Fig. 209. — Healed supracondylar fracture. Dressed in extension which caused union 
\v-ith the angularity evident between the fragments. If the forearm had been folded 
over exactly on the arm, this angularity could not have occurred. 

Fig. 210. — Dicondylar fracture. Note that the plane of separation passes through 
the olecranon fossa. There is callus beneath the stripped periosteum. 



class of housebreakers who will murder, are subject to these fractures 
above the right elbow (Figs. 207, 208, and 209). These are received 
from a fall, a result of jumping from windows when caught, or as has 
been suggested, by the sharp tap of a policeman's hickory club. 
When the injury is healed the criminal can never again "pull a gun" 



398 



FRACTURE OF THE HUMERUS 



and shoot straight, as the use of the elbow has been greatly impaired 
and the carrying angle changed (Figs. 210, 211, and 212). 




I 



Fig. 211. — An open dicondylar fracture. The upper humeral fragment protruded 
through the skin. Both forearm bones fractured also. 




Fig 



212. — Result obtained in the open fracture shown in the preceding, 
was later operated on for non-union in the radius. 



The forearm 



MECHAXISM OF FRACTURES OF END OF HUMERUS 399 

Pathology. — The pathology is interesting. Infracondylar fractures 
occur in the flattened-out portion of the bone previously described, 
in which the Hue of fracture passes transversely from epicondyle to 
epicondyle (epitrochlea) with the line higher on the posterior than on 
the auterior surface of the humerus, so that the lower fragment is dis- 
placed backward. The trauma in these cases is received with the arm 
in extension, but rarely the lower fragment may be displaced forward, 
giving a fracture of flexion, as described by Kocher. Dicondylar frac- 





FiG. 21.3. — Dicondylar fracture. A 
good reduction \\-ith little extra callus 
around the internal epicondyle. 



Fig. 214. — Healed condylar frac- 
ture. The reposition is less perfect 
than the preceding. Note the callus 
about the internal epicondyle. 



ture (Figs. 213 and 214), called low supracondylar fracture by Stimson, 
has a similar transverse plane of separation which crosses the olecranon 
fossa, and is above the epiphyseal line. In this type lateral displace- 
ment outward or inwanl is more common than posterior. Chutro, 
quoted by Ashhurst,' reported 5 cases of an uiuisual type of dicon- 
dylar fracture first described by Posadas of Buenos Aires, in which 



1 Fractura de la Extromiflafl Inferior del Huniero en 
1904. 



Ninos, Te.sis, Buenos Aire.«, 



400 



FRACTURE OF THE HUMERUS 



the lower humeral fragment is displaced forward into the elbow, 
complicated by posterior displacement of the forearm bones. Chutro's 
cases all recovered with elbows ankylosed in complete extension. 
Ashhurst^ reports 1 case which he recognized and operated on with 
a happy result, 





Fig. 216. — Dicondylar fracture in a child. Al- 
though the forearm is flexed, it is not flexed enough 
to cause complete reduction. 



Fig. 215. — A good reduction 
of dicondylar fracture. Note 
the callus found beneath the 
stripped-up periosteum. 




Fig. 217. — A less perfect reduction with more 
callus. Note that the plane of separation passes 
from before backward and upward. 



If the etiology is indirect violence from the forearm, the lower 
fragment is usually pushed backward and held there by the contrac- 
tion of the triceps muscle, the periosteal bridge, and the brachialis 
anticus and biceps, which pull the forearm up. The muscles of the 
forearm arising from the epicondyles retain the lower fragment in 



1 Loc, cit. 



MECHAXISM OF FRACTURES OF END OF HUMERUS 401 

flexion when the forearm is fully extended. The olecranon is pulled 
upward, and difficulty lies in distinguishing this fracture from a pos- 
terior dislocation of the forearm bones at the elbow. The lower frag- 
ment may be displaced forward with either mechanism as a cause, 
in which case the sharp edge of the upper fragment can be palpated 
above the elbow, and the forearm seems lengthened. The lower 
fragment may be split down toward the joint with separation of 
the fragments, or a shell may be split off the anterior or posterior 






Fig. 218. — Dicondylar 
fracture with lateral dis- 
placement. 



Fig. 219. — Dicondylar fracture 
with little displacement in a child. 
Note that the fracture plane is 
well above the epiphyseal line, 
the two epiphyseal centres just 
appearing below. 



Fig. 220— Dicon- 
dylar fracture in a 
child. 



surface of either the lower fragment or the shaft, complicating the 
break. Long strips of periosteum are lifted up in a similar manner 
(Figs. 215, 216, and 217), and if reduction is not complete callus 
may form beneath these and furnish great thickening of the bone 
with corresponding loss of function (Figs. 218, 219, 220, 221, and 222). 
Diagnosis. — If the lower fragment is split, the line may be but a 
crack, or the case may merge into one of fracture of the condyles, or 
a T-fracture. The lower fragment separating into two or more pieces 
may be wedged apart by the lower end of the shaft, which pushes 
26 



402 



FRACTURE OF THE HUMERUS 



down between them, and may come to lie in the joint, pressed against 
the uhia (Figs. 223, 224, and 225). If heaUng is permitted unreduced 





Fig. 221. — Lateral view of green-stick 
dicondylar fracture in a child. Note that 
the incomplete plane of separation is 
almost vertical. 



Fig. 222. — Dicondylar fracture in a 
child. Lateral displacement and im- 
paction. 





Fig. 223.— The fracture at the elbow 
opening into the joint. The upper frag- 
ment has been pushed down between the 
two lateral ones. 



Fig. 224. — Repair of the preceding. 
One fragment nailed on by an ivory 
peg, the other wired in position. In- 
cision on each side of elbow. 



MECHANISM OF FRACTURES OF END OF HUMERUS 403 

in this position, the arm is shortened, great thickening of the upper 
part of the elbow exists and probably also a complete bony ankylosis 
with the forearm fixed in a position established by the dressing. 

For differential diagnosis refer to the expedients mentioned above. 
If there is simple supracondylar fracture, transverse or slightly oblique, 
with the lower fragment pushed backward and upward, the forearm 
appears lengthened, but examination reveals the following: 




Fig. 22.5. — Lateral view of the repair. This does not look like an excellent result, 
but the shaft fragment has been removed from the joint. The functional result was 
fair to good. 



1. The points of the olecranon and condyles are in normal rela- 
tion; in dislocation they are not so. 

2. The axis of the humerus is not normal, as evidenced by the ruler 
test. 

'.]. The forearm is of normal length from the internal condyle to the 
styloid process of the radius; in dislocation it is shortened. 

4. The arm is shortened from coracoid to internal condyle; in dis- 
location it is normal. 

5. The deformity can be reduced but quickly recurs. 



404 FRACTURE OF THE HUMERUS 

G. The lower end of the upper fragment is felt above the elbow 
crease in front. 

7. Crepitus is usually present in fracture when complicated by a 
splitting apart of the lower fragment. 

If in doubt as to diagnosis treat the injury as a fracture, not as a 
dislocation. 

Positive diagnosis is very difficult on account of the great swelling. 
By waiting for this to subside and by finding increase in the width 
of the elbow posteriorly, with looseness of each condyle on manipula- 
tion and the bony projection of the upper fragment forward above 
the elbow, one establishes diagnosis. In supracondylar fracture this 
projecting edge of bone is rougher than in the dicondylar variety, 
which also protrudes less. This fracture involving the elbow move- 
ment is very serious on account of injuries to vessels and nerves and 
possible loss of blood supply to the hand. It is imperative that early 
diagnosis and treatment be instituted. 

Treatment. — Treatment must aim to restore the fragments to posi- 
tion and relieve pressure on nerves and bloodvessels. Bony ankylosis 
must be considered from the very first, and it is best avoided by early 
and complete reduction (Figs. 226, 227, and 228). If the lower frag- 
ment is displaced backward, it may be pulled down and into position 
on the upper fragment by one's grasping the forearm and wrist pulling 
down, slightly hyperextending first but not enough to endanger the soft 
parts in front. This unlocks the fragments and permits reduction. An 
assistant makes counter-extension by pulling backward and upward on 
the arm, meanwhile pressing against the lower fragment to push it into 
position. When the lower fragment is split and the end of the upper 
shoved between its parts, this correction must then be aided further 
by pressing of pieces of the lower fragment together, but it is quite 
impossible to hold them in position by manipulation. 

The lower fragment having been brought into line, its position 
is secured by flexion of the forearm as far as possible with the hand in 
full supination. It is wise when correcting the carrying angle in this 
process of hyperflexion, rotating the lower fragment on to the humerus, 
for one to abduct the forearm slightly, as a little overcorrection with 
resultant cubitus valgus is less noticeable and disabling than cubitus 
varus (Fig. 229) . When the joint is so flexed the point of insertion of the 
triceps muscle is brought anterior to the longitudinal axis of the humerus, 
and while holding the lower fragment in a sling-like grasp, it also 
tends to crowd it into place. With an intact triceps the lower fragment 
cannot be displaced. The angle of fixation should never be less than 
GO degrees, as this holds the fragments firmly together by means of the 
ligamentous structures and the soft parts, and no motion can take 
place at the elbow, although the shoulder is free for all movements. 
This position uses the fibers of the triceps tendon as a posterior splint, 
the tissues in front of the elbow pushing the fragment back against 
it. To maintain this, a moulded plaster splint from shoulder to wrist 
held together by adhesive is used — or the arm may be strapped up 



MECHAXISM OF FRACTURES OF END OF HUMERUS 405 




Fig. 226.— T-fracture of the lower 
end of the humerus. Some retention 
of fragments in position. 





Fig. 227. — Lateral view of the 
preceding. 




Fig 228. — Healed reduction of the 
preceding. 



Fio. 229. — Healed T-fracture of the 
elbow. Note the new angle given to the 
forearm. 



406 FRACTURE OF THE HUMERUS 

ill this position by adhesive. A favorite adhesive-plaster dressing is 
one first applied about the forearm and then the arm with final turns 
oiu'irclino" both and covering the elbow. The shoulder need not be 
innnobilized.^ Hartshorn- suggests an additional adhesive strip along 
the dorsum of the injured forearm, over the uninjured shoulder, to 
give the support of a sling. This makes the dressing snug but pre- 
vents shoulder motion, which can be safely enjoyed by means of a 
neck sling. Even with much swelling around the elbow, it is surprising 
how little this position of exaggerated flexion affects the circulation. 
Flexion must be held for four or five weeks at least; then the arm can 
be gradually lowered and given passive motion, but never beyond the 
arc which is painless. The extreme flexion can be lessened in favorable 
cases after ten or twelve days gradually and the arm brought to an 
angle of not more than 60 degrees. This type of fracture demands pro- 
longed immobilization, the prognosis and final result depending on 
the simplicity of the break, its early reduction and proper immobil- 
ization. If motion is started too soon or carried beyond the painful 
point, irritation is set up which causes a great excess of callus with 
thickening and subsequent loss of motion or ankylosis. One needs 
but to try this treatment to become an advocate of it. 

When the lower fragment is displaced forward, it should be reduced 
by traction of the parts below the elbow, with the shaft of the humerus 
pushed forward and then treated in the same position of flexion. 
Either an anterior or posterior moulded splint may be used, or they 
may frequently be combined to advantage in cases where long 
immobilization is wished. 

Fractures of more than a couple of weeks' standing in which callus 
has already been deposited in the space beneath the periosteum stripped 
up from the shaft are treated under anesthesia. Forcible flexion and 
extension at the site of fracture is then done (arthrolysis), the callus 
broken loose, and after the lower fragment is forcibly refractured from 
the upper, it is brought into hyperflexion and overcorrected in abduc- 
tion (valgus). If full flexion cannot be reached at the first trial, the 
attempt should be repeated in a few days, with more flexion at each 
trial until a satisfactory position is attained. 

If these means are not successful, as in cases of long standing, open 
operation is done, and by osteoplasty the bone is cut through and 
replaced in good position, the arm being brought into the hyperflexed 
position. Supracondylar osteotomy is not performed so much for 
the disability of gunstock deformity as it is to correct the visible 
changed axis of the arm on esthetic grounds. An internal fixation 
splint is not always needed, but every possible bit of bone should 
be saved, and the periosteal covering should be allowed to remain 
intact in part of its circumference. Von Saar^ has reported 6 cases of 
this character in 2 of which the radial nerve was entangled in the 

1 Lusk, Ann. of Surg,, xlviii, 432. 

2 Med. Rec, New York., Ixxxvi, No. 18. 

3 Deutsch. Ztschr. f. Chir., exxviii, S. 29. 



MECHAXISM OF FRACTURES OF END OF HUMERUS 407 

callus. Five of these cases were old; his results were verv good in 
all.i 

Operation is more often reserved for those cases in which the lower 
fragment is split apart and the shaft enters between the pieces, for 
T- and Y-fractures, and other irreducible cases. To approach, longi- 
tudinal incision must be made on each side of the elboAV just above 
the condyles. By dissection the surgeon avoids the joint surface, 
either identifies the ulnar nerve on the inner side as it curves down 
behind the inner condyle and retracts it out of the way, or by going 
a little anterior avoids it as a source of worry. He exposes the frac- 
ture on both sides, may tunnel under the tissues in front of the elbow, 
keeping close to the bone with a dull elevator, and avoids important 
structures. The problem of bringing down the broken-off and sep- 
arated condyles and attaching them to the end of the shaft then 
presents itself. By traction on the flexed forearm this may be accom- 
plished, aided by bone-grasping forceps working in the wound. One 
side at a time has to be attached. The outer side may be brought 
down first and fastened to the shaft by a nail or ivory peg, then atten- 
tion is directed to the more important inner condyle. The extension 
of the forearm, tln^ough the pull of its flexor muscle, makes traction 
on this condyle, and it can generally be worked into place and held 
there either by a wire into the shaft or a wire thrown around both 
lower fragments and binding them together. These fragments are 
also nailed together. The closer they fit and the smaller the fissure 
between them which opens into the elbow-joint, the less danger of 
bony ankylosis awaits. The position and avoidance of the ulnar 
nerve must be remembered at all times When the fragments are 
in position, they must be held there, and one should be sure that the 
carrying angle of the forearm is normal. The muscle and skin closure 
follows, after which the arm and forearm are stiffened into position 
by a heavy moulded splint which must pass down to the finger bases 
and give perfect immobilization in as much flexion as can be secured. 
If the displacement warrants, injured elbows put up in marked flexion 
are treated best because: 

(1) When they are removed from the splint, it is easier to get the 
patient to exercise the arm in the direction of extension. 

(2) If ankylosis or limited motion follows as a result, the forearm 
and hand are in a more favorable position for use. 

(3) If stiffness and limited use follow, they are less apparent in a 
position of flexion. 

(4) Advantage is obtained of the use of the tissues for holding the 
correction as outlined above. 

8. Fracture of the Condyles Alone. — The internal condyle may be torn 
off" by indirect violence accompanied by capsular and muscular action, 
and the external condyle may be broken by transmission of violence 
from the head of the radius, or by falls on the side with the arm abducted. 

• Lexer, Zentralbl. f. Chir., 191.3, Xo. 10, S. G0.3; Steinman, Beihelfte z. Med. Klitiik, 
1912. 



408 



FRACTURE OF THE HUMERUS 



These fractures vary in extent; a small chip of bone may be broken 
oi\\ or the whole corner of the condyle extending well into the joint 
may be split ofl' (Figs. 230, 231, 232,'and 233). The inner condyle is 
most frequently involved on account of falls on the elbow with the 
arm extended to catch the body weight, the violence being transmitted 
through the ulna to the trochlea and a fragment split off. Children 
usually fall on the outstretched hand and hence seldom suffer this 
fracture. The line of fracture is oblique and is found extending from 
the epicondyles into the trochlea, with serrated and uneven edges. 
Injuries on the inner side are more extensive, as a rule, than those of the 





Fig. 230. — Comminuted fracture of 
the internal epicondyle part way 
through the epiphyseal line. 



Fig. 



231. — Internal epicondyle fracture 
in an adult. 



external condyle. Because of the lack of support of the internal con- 
dyle, the broken-off fragment of which always ascends, the forearm 
is swung in toward the body by its own weight and the carrying angle 
disappears. Manipulation of the internal condyle causes crepitus. 
The oblique line of fracture enters the joint at any point as far laterally 
as the capitellum. The axial continuity between the humerus and the 
ulna is lost and in a corresponding degree the function of the forearm 
is lost, as the ulna is the bone which gives stability to the elbow, the 
radius being more concerned with the wrist and hand. The elbow- 
joint may be freely movable in any direction. When the coronoid 
or olecranon fossae are involved, the resulting deformity simulates a 



MECHANISM OF FRACTURES OF END OF HUMERUS 409 

dislocation, but examination will reveal the loose fragments and settle 
the matter even if there is the customary swelling and ecchymosis. 
\Yhen the forearm is extended, it can be moved from extreme adduction 
to abduction, and crepitus is present. 

Should a small tip of the epicondyle be broken off, it is pulled down- 
ward by its muscular attachment, the flexors of the forearm. In 
young adults this may be accompanied by a starting of the epiphysis, 
the displacement being slight. Where the condyle is broken off into 
the joint, the loose fragment is pulled upward and rides on the shaft 
of the humerus. In such displacement the olecranon seems more 





Fig. 232. — Lateral view of internal 
epicondyle epiphyseal separation in a 
child. 



Fig. 233. — Fracture of the internal 
epicondyle, displacement upward and 
forward. 



prominent than usual, and it is pushed backward a little, while in 
front the broken edge of the humerus may be seen and felt. The ulnar 
nerve crossing just behind the internal condyle may be injured pri- 
marily in this fracture or may be secondarily involved from contusion 
with traumatic neuritis and consequent palsy of the muscles supplied 
by it. Late ulnar palsy may follow from callus compression. 

Small detached pieces of the condyles, as a rule, heal to the rest 
of the bone and cause no trouble (Fig. 234) . Under some circumstances 
by position just below the joint surface, especially on the inner side, 
they may interfere with flexion of the forearm, and when a large piece 



410 



FRACTURE OF THE HUMERUS 



into the joint is broken and slips npward, it may allow but slight 
movement of the joint. This is because the uhia is displaced upward 
with it, and if healed in that position, the forearm is in adduction. 
TJiis is described as cubitus varus. The normal carrying angle is 
obUterated, and but little flexion, rarely beyond a right angle, is 
possible. When the external condyle is broken in the same manner, 
the carr.ying angle is exaggerated, the forearm is in greater abduction, 

and there exists cubitus valgus. Any 
degree of these deformities may exist, 
depending on the extent of the fracture in 
the condyle. 

Treatment. — Treatment of small frag- 
ments consists in replacement of the loose 
piece by manipulation and immobilization 
of the arm, the forearm in flexio», with 
pains taken to maintain the carrying angle 
by abduction of the forearm in fractures 
of the internal condyle. A moulded plaster 
splint posteriorly with a pad holding the 
fragment in place is good treatment. Re- 
sults should be checked by skiagram. 
Fabian^ describes 24 cases of fracture of 
the external condyle treated at Leipzig in 
the last three years; 9 were operated upon, 
4 nailed, 1 had partial and 4 total extirpa- 
tion of the detached fragment, all opera- 
tions on account of functional disturbances 
and none for cosmetic purposes. As a 
result of his experience he favors total 
extirpation of the fragments. 

Fracture of the internal condyle into the 
joint is difficult to reduce and hold reduced. 
These fractures are often caused hy direct 
violence and are rarer than the best teachers 
formerly supposed. Ashhurst says that 
Chutro found but 2 in 106 cases, Monchet 
1 in 17 cases, and Kocher 6 in 45 fractures 
of the lower end of the humerus. By 
complete extension of the forearm the condylar piece may be pulled 
down into place, but w^hen the position is released, it slips out imme- 
diately. Serrated and locked edges make reduction by manipulation 
very difficult. Hyperflexion is the best position; with that the frag- 
ment can neither ascend nor rotate. Considering the possibilities of 
restricted motion and the danger of excess callus or ankylosis, many 
of these cases are best treated by open operation, particularly if the 
ulnar nerve is involved. 




Fig. 234.— Ununited frac- 
ture of the internal epicondyle. 
There is evidence of callus 
formation about the external 
epicondyle and above the site 
of fracture. 



Deutsch. Ztschr. f. Chir., cxxviii, 409. 



MECHANISM OF FRACTURES OF END OF HUMERUS 411 

The surgeon makes incision over the injured condyle in the long- 
axis and a^'oiding the important nerve, he exposes the fragment. By 
grasping it with a forceps, extending the arm as a help, he can bring 
the piece into good position, imless the locking and serration cannot 
be overcome. When proper position is secured a nail or screw is 
driven through the fragment into the shaft of the humerus (Figs. 
235 and 230). The arm is put up in moulded plaster in a half-flexed 
position for six weeks, and after-treatment follows the general rule 
of fractures near joints in regard to use and motion. 

In some instances these fractures are not recognized and are insuf- 
ficiently immobilized or otherwise mismanaged; then the condylar 





Fig. 23.5. — Operative repair by nailing 
of broken-off condyle. 



Fig. 236. — Side view of the preceding. 
The reduction seems fair but functional 
result was poor. 



fragment remains loose and yet interferes with use of the elbow. 
Healing can take place with the fragment displaced, with cubitus 
\ arus or valgus, and as long as elbow movement is satisfactory, much 
may be overlooked in the way of deformity. For loose fragments, 
for excess callus inhibiting joint motion or interference with the 
nerve, operative treatment is indicated. Each case must be studied 
with good skiagrams to aid, and as little bone removed or such areas 
freshened and reapplied with an internal splint as the findings demand. 
Xerve involvement is very serious, and after operative freeing, many 
weeks of massage and electric treatment are needed to get effect. 
After an incarcerated nerve, as the ulnar, is freed, if there is not suffi- 
cient fatty or loose subcutaneous tissue present in the operative field, 



412 FRACTURE OF THE HUMERUS 

a suitable piece of fascia lata with fat attached should be removed 
aud wrai)ped carefully arouud the nerve. It is then tucked up out 
of the way of the callus by delicate sutures. 

9. FractiUTS or separation of the lower epiphysis of the humerus 
are the result of falls on the elbow or forearm in children, the bone 
yielding across this softer area. Direct violence is also a cause, but 
it may act in conjunction with indirect violence transmitted by the 
bones of the forearm. In these separations the upper end of the radius 
and ulna are seldom broken. Force transmitted by them is expended 
through the insertion of the capsular ligament of the elbow-joint, 
which is firmly attached above the epiphyseal line. As in ankle and 
wrist fracture, the ligaments, especially in adolescence, are stronger 
than the growing cartilaginous epiphyseal area, and the latter yields 
when sudden force is applied. In early youth both condyles are 
included in the shaft portion of the epiphysis, and fractures up to 
twelve or thirteen years generally include both condyles, the shaft 
above being torn off in a rounded edge. 

Epiphyseal separation is rare after fifteen years of age and is most 
frequent about the twelfth year. As the cartilage gives little evidence 
of separation in the roentgenogram, this separation is difficult to 
diagnose by that means, for if the diaphysis is broken across above the 
epiphyseal line the fracture must be classed as dicondylar. Diagnosis 
depends on the symptoms and physical findings, or if the lower frag- 
ment is displaced laterally the roentgenogram will help. 

The pathology is that of irregular separation with rounded edges 
through the soft tissues of the epiphysis. The lower fragment may be 
displaced forward or backward, and lateral displacement to either 
side may accompany it. Should the violence be received more directly 
on the elbow area after the separation has started, an impaction 
may result, and the lower and softer fragment is severely compressed 
and deformed. There is a constant hemarthrosis with much swelling, 
crepitus is usually faint or absent, and the deformity varies with 
the displacement. If lateral, the forearm seems lengthened and 
displaced laterally with a change in the carrying angle; if anteropos- 
terior, the forearm also seems lengthened, the arm shortened and the 
end of the diaphysis may be felt in front or behind, the relative position 
of bony points at the elbow remaining normal. In all injuries to the 
elbow in adolescence, where fracture and separation of the olecranon 
cannot be made out, this fracture should be excluded at once. 

Proximity to the joint and interference with arm function demand 
that these fractures should be carefully reduced as soon as possible 
and the result checked by skiagram in two directions. Treatment 
can be given when first seen, as even impacted cases will yield to 
manipulation. The lower fragment is loosened a little by extension 
of the forearm in the grasp of the surgeon, the assistant holding the 
arm. It is then pushed into place with one hand according to the 
displacement, while the forearm is brought up into complete flexion. 
The same permanent dressings as are used in elbow fractures are 



i 



MECHANISM OF FRACTURES OF END OF HUMERUS 413 

applied, or the hand may be strapped down over the shoulder on the 
same side. Immobilization should last two or three weeks and then 
passive motion cautiously begun, the arm still retained during the 
interval in flexion. 

^Manipulation failing, operative treatment is indicated to restore 
the epiphysis to normal place. Lateral incisions are made (sometimes 
one side is sufficient), and after the opening of the hematoma under 
the periosteum, which may remain intact, the line of separation can 
be seen and a blunt elevator or chisel, aided by external manipulation, 
will suffice to lift the lower fragment into position. As the line of 
fracture is soft, reposition holds of its own adherence, and rarely is 
fixture by a foreign body needed. In fact these cases do not stand 
foreign material at all well, and it is a question if it is not better to 
put up with a slight deformity rather than run the risk of infection 
or secondary operation. 

Fractures of epiphyseal separation of the epitrochlea consist of the 
upper part of the internal epicondyle, not the whole epicondyle. They 
frequently are a complication of elbow-joint dislocation. 

Fracture of the trochlea is rare; Stimson reported a case. Fracture 
of the external epicondyle is very unusual. If large enough to include 
the joint, it is best to class it as fracture of external condyle. 

Fracture of capitellum is known — Stimson has reported a case. 
Ashhurst produced one experimentally ; the fragment is intra-articular. 

In a small percentage these fractures are complicated by splits in 
the diaphysis. Compound fractures in this region are treated with 
the general care for that class of injury. The fragments are replaced 
and wide drainage into copious sterile dressings supplied. No foreign 
material is put into the bone and the arm is dressed in flexion. Should 
no infection or a slight skin infection only be present, the wound is 
dressed without the arm being released from its flexion, and fair 
results are to be expected. Deep infection, threatened gangrene 
of the hand on account of circulatory disturbance, or great pain will 
demand loosening of the dressings and a release of position with sur- 
gical provision for proper drainage. Effort is made to save the limb 
and avoid the toxemia of sepsis, the fact of fracture being made second- 
ary. Deep infection involving the bone or joint will lead to a long 
disability with resulting restricted use of the elbow. If this is fore- 
seen, it is best to have ankylosis occur with the forearm flexed so that 
the hand may be of use. After complete subsidence of infection, 
removal of dead bone and a closing of all sinuses, arthroplasty may be 
attempted with the use of neighboring tissues or transplanted fascia. 
Other treatment consists in the freeing of the olecranon and head of 
the radius with partial resection of them. The bare ends are covered 
with soft tissues, and by means of early passive motion a pseudar- 
throsis is developed which leads to a more useful joint. 



CHAPTER XVI. 
DISLOCATIONS OF THE SHOULDER. 

In the remarks preceding the discussion of fracture of the humerus 
the anatomy of the shoulder-joint has been mentioned, and the abduc- 
tion mechanism of causing injuries of this joint has been outhned. 
Before the discussion of dislocation it is necessary that a few points 
be recalled. The whole head of the humerus does not lie within the 
glenoid cavity, as the femoral head does in the acetabulum. Only 
the posterior portion rests against the glenoid surface which looks 
outward and forward and is less than half the extent in surface of the 
articular part of the head of the humerus. The bone edge of the 
glenoid is deepened a little by a rim of cartilage, and the articular 
capsule and long head of the biceps tendon are attached to it. Attached 
to the tuberosities of the humerus are the spinati, subscapularis, and 
other muscles. The ligaments, the muscles, and atmospheric pressure 
hold the humeral head in place. Important landmarks are the acro- 
mion, which can be felt above the humeral head in any patient unless 
it is broken, and the coracoid, lying just medial to the head. Con- 
necting these two processes is the strong coraco-acromial ligament, 
which also guards the joint. The head of the humerus constitutes the 
other landmark, and it is really the most important, as it is the one 
which moves out of place. Methods of palpating the head and tuber- 
osities are given in the discussion of fracture. The surgeon must 
familiarize himself with the normal position of these joints and with 
the "feel" of the head and tuberosities as they roll under the fingers 
pressed lightly against them when the arm is rotated. The opposite 
joint is used for comparison. The shoulder-joint possesses a wide 
range of motion because of the structures described, and because the 
articulation includes the scapula, which has movement on the trunk. 
When the humerus is not permitted this freedom of motion, and it is 
felt to lie in an abnormal position, dislocation is understood. 

Frequency and Classification. — At the Cook County Hospital there 
were 409 dislocations of the shoulder, or 52.8 per cent, of a total of 775 
luxations. Stimson's statistics gave 617 shoulder dislocations in a 
total of 1527. Malgaigne's and Gurlt's collections showed 65 per cent, 
and 58 per cent, respectively of the shoulder. The luxation is about 
ten times commoner in men than women, and the largest proportion 
occurs in the third and fourth decades of life. In the first decade 
fractures of the clavicle are a more frequent consequence of falls which 
in adults produce shoulder dislocation. The forms of luxation are: 
anterior, posterior, downward, and upward. These terms can be 



AXTERIOR DISLOCATIOXS 415 

subdivided in accordance with the degree of displacement, and the 
following simple classification fits all forms. 

1. Anterior dislocations. 

(a) Subcoracoid complete — common form. 
(6) Subcoracoid incomplete {subluxation). 

(c) Intracoracoid. 

(d) Subclavicular. 

2. Posterior dislocations. 

(a) Subacromial. 

(h) Subspinous (scapular spine). 
3. Downward dislocations. 

(o) Subglenoid. 

(6) Erecta. 
4. Upward dislocations. 

(a) Supraglenoid |Both very rare and accompanied by 

(6) Supracoracoid J fracture. 

1. ANTERIOR DISLOCATIONS. 

Subcoracoid Dislocation. — Subcoracoid dislocation is the common 
luxation at the shoulder. The head leaves its contact with the glenoid 
surface and moves forward and inward until it lies beneath the point 
of the coracoid above. ^Yhen the head assumes a position farther 
inward so that more than two-thirds of its mass is found inside the 
line of the coracoid, the luxation is termed intracoracoid, or, if a still 
greater displacement inward exists, subclavicular. This differentia- 
tion is merely one of degree; it is helpful in clinical description. 

The causes are indirect and direct violence and muscular action. 
The abduction of the arm in the mechanism described for shoulder 
injuries is the usual cause. The outer surface of the humerus impinges 
against the acromion or the coraco-acromial ligament, and the head 
of the bone, levered out of place, escapes through a tear in the capsule 
at the opposite point, the antero-inferior surface. As the head escapes, 
the arm usually descends from its abducted position, and the humerus 
is pulled inward by the attachment of the pectoralis major and latis- 
simus dorsi muscles. It is prevented from dropping downward by 
the holding of portions of the inelastic capsule on the external lateral 
aspect of the joint, which become taut and prevent a wide displace- 
ment of the head inward. Cotton^ believes that it is folly to attempt 
to determine the exact nature of the fulcrum action and thinks that 
the contracted tendons of the adductor muscles are entitled to con- 
sideration as a leverage point. Most authorities agree, however, that 
the method outlined in abduction injuries causes the majority of sub- 
coracoid flislocations and that all the factors mentioned have an 
influence. 

Direct violence furnished by blows or falls on the shoulder may 

1 Dislocations and Joint Fractures, 1910, p. 155. 



416 DISLOCATIONS OF THE SHOULDER 

cause dislocation by driving the head out of the glenoid. These luxa- 
tions require great force and are often complicated by fracture of the 
acromion, if the force comes from above on the glenoid, and of the 
scapular neck, if the force is directed horizontally. The capsule is 
generally torn extensively. Eve^ recorded a case of subcoracoid dis- 
location by direct violence in which the capsule remained unruptured. 

INIuscular action causes shoulder dislocation, either by volition or 
during active use of the arm in reaching, throwing or grasping. The 
volitional type is really to be classed with habitual dislocation, and 
the spontaneous dislocations during muscular activity are often 
attended by some pathological change in the tenseness of the capsule 
or by joint disturbance. Inward rotation by muscular action undoubt- 
edly causes anterior dislocation and is seen in football players, in 
wrestlers, and in men making muscular efforts in weight-carrying. 
This type supports the idea of causative mechanism expressed by 
Cotton, namely, the leverage action of the muscles alone without 
bony impingement, because there is no abduction of the arm. It is 
sufficient to know that all the causes described cause luxation forward 
at the shoulder. They can be verified on the cadaver, and in traumatic 
lesions of any sort, especially in fracture and dislocation, it is nearly 
impossible to state the position of a limb at the exact instant of the 
injury. 

Pathology. — ^The frequency of shoulder dislocations and complica- 
tions which lead to an early fatal termination have furnished excellent 
opportunities for postmortem examinations of the traumatic changes. 

The capsule is torn. The tear involves the inner anterior portion, 
extending for a varying distance along the glenoid rim. It may include 
a half of the circumference or be very small and incomplete, inasmuch 
as the heavy fibrous portion is ruptured, and the more elastic synovial 
surface retains continuity by stretching. The coracohumeral bands 
extending from the coracoid to the tuberosities are rarely torn and 
assist in limiting the amount of displacement (Fig. 237). The perios- 
teum is sometimes stripped up. The tuberosities of the humerus are 
frequently torn out by the pull exerted from the stretched attached 
muscles. The greater tuberosity is pulled by the spinati and teres 
minor muscles and is frequently injured (see Fractures of the Greater 
Tuberosity). The lesser tuberosity is seldom injured by the subscapu- 
laris. These muscles may be lacerated or compltcely torn asunder 
by the force of the luxation. 

The cartilaginous rim of the glenoid may be split off and small 
fragments of bone loosened which obstruct reduction or favor recur- 
rence. Bony outgrowth from these bone lesions often causes a 
restriction of motion later. The head of the humerus may be indented 
or chipped, and in old dislocations the presence of a groove in the 
bone, probably caused by pressure against the glenoid, has been 
remarked by several surgeons. When the greater tuberosity is 

1 Med. Chir. Trans., London, 1880, Ixiii, 317. 



AXTERIOR DISLOCATIONS 



417 



detached, two displacements are possible. The bone fragment may 
remain partly in position held by some periosteal shreds, or it may 
be widely retracted and come to lie high up beneath the acromion. 
After reduction, if the bone fragment does not interfere with replace- 
ment, union with the head in an abnormal position may occur, with 
formation of much callus. This bone growth obstructs shoulder 
motion, especially abduction. As the tuberosity forms the posterior 
edge of the groove in which the long head of the biceps passes, the 
tendon may be exposed and displaced backward on the outer side of 
the head. By impinging on the roughened bone surface this tendon 




Fig. 2.37. — Complete subcoracoid dislocation of the humerus, 
glenoid displaced forward and inward. 



The head out of the 



ma}' seriously obstruct reduction, or it may even be twisted about 
the neck of the bone when the humerus lies far forward, and make 
reduction impossible. 

The position of the head of the humerus varies in every dislocation. 
In the forms of subluxation forward it lies just on the glenoid rim; in 
complete dislocation it lies outside of and against the glenoid or deeper 
against the scapular neck, the position depending on the muscular 
attachments and the capsular portions which are untorn. Usually it 
lies high up against the coracoid, and the secondary position after 
dislocation may place it well within the coracoid line toward the 
sternum. The humerus assumes also a position of rotation inward or 



418 



DISLOCATIONS OF THE SHOULDER 



outward, according to the character of the causative trauma and the 
compHcations of muscle rupture and tuberosity fracture. The usual 
finding is a slight inward rotation (Fig. 238). 

Other important pathological complications concern the injuries of 
bloodvessels and nerves. These have been given in the general chapter 
on Pathology of Dislocations, but are so important that the surgeon 
must bear them in mind when treating every case of shoulder dis- 
location. Before attempts at reduction are made, examine the arm 
carefully for any evidence of nerve and bloodvessel damage. These 
structures are injured by the same force which causes luxation, an 




Fig. 238. — Subcoracoid dislocation of the humerus with fracture and displacement of 
the greater tuberosity. Looked at from behind, the scapular shadow is omitted. 



avulsion of the brachial plexus at the spine, for example, or they are 
injured by the pressure of the displaced head during and after dis- 
placement. If the condition of injury, particularly of the nerves, is 
not noted until after reductive attempts, the surgeon comes in for a 
large share of blame which may not belong to him. All branches of 
the brachial plexus, or only one branch, may be torn or bruised. The 
circumflex nerve is also frequently injured, with deltoid paralysis. 
This injury may be permanent, the muscles supplied may never 
regain function, and when the shoulder girdle is involved there is loss 
of tone in the capsule and loss of muscle power about the joint, with 
a functional weakness. 



ANTERIOR DISLOCATIONS 419 

]Many of the serious injuries of the bloodvessels have accompanied 
manipulative efforts at reduction of long-standing dislocations. There 
are a few instances of vessel rupture from the luxation alone. A hema- 
toma forms which often pulsates, and if the artery is torn, the radial 
pulse is obliterated. The pulse may also be lacking because pressure 
over the axillary artery obstructs it. Korte^ records an instance of 
dislocation sustained by a forty-year-old man. The radial pulse was 
absent but reappeared immediately after reduction. Another interest- 
ing case illustrating pressure on the axillary artery by the displaced 
head was reported by Ericksen.^ The patient had a wound of the 
forearm which severed the radial and ulnar arteries. As long as the 
dislocation remained unreduced there was no hemorrhage from these 
cut vessels, but when reduction was accomplished they promptly 
began to bleed. Vincent^ reported a case in which engorgement of 
the veins of the arm was caused by the dislocated head pressing on 
the axillary ^ein. After reduction the venous edema and hyperesthesia 
from nerve pressure disappeared. A slight change of position of the 
arm may permit the blood stream to pass, and pulse will reappear 
before reduction. The circumflex and subscapular vessels have been 
torn, as has also the subclavian. Bloodvessel injury with a rapidly 
forming hematoma calls for radical and immediate surgical inter- 
ference. Venous rupture offers a better prognosis than arterial, for 
obvious reasons. 

The literature of accidental lesions of the axillary vessels is very 
extensive, considering the total number of cases on record, and the 
reader is referred to a few papers which give excellent bibliographies. 
iMakara in the surgical clinic at Budapest from 1867 to 1895 found 
that there were 138 old luxations treated; 81 of these involved the 
shoulder, only 2 of which produced axillary vessel injury. The 
most complete articles are by Korte,^ Guibe^ and Andrews.^ Korte 
collected 44 cases and reviewed Stimson's collection made in 1885. 
The mortality was about 70 per cent. More than half the cases 
were in fresh dislocations, that is, displaced three weeks or less. More 
than one-third were caused by reductive efforts, and 3 of the cases 
were directly traced to the trauma of dislocation. The axillary artery 
was injured 35 times, the artery and vein twice, twice the exact vessel 
injured could not be located, and 3 cases were cured without operation 
and no certain diagnosis was made. The final outcome was 31 deaths 
and 12 cures. Andrews^ adds 2 more cases which are not mentioned 
elsewhere in the literature. One was seen by Dr. Ferguson and the 
other by Dr. A. J. Ochsner in Parke's clinic at Rush College. Both 
had a fatal termination, Parke's case after ligation of the subclavian. 
The last extensive review by Guibe counts 78 cases. He found that 
in 12 cases the accident existed either before reduction or without 

' Arrh. f. klin. C'hir., Bd. xxvii, 039. ^ Handbuch dcr Chir., i, 374. 

These de Paris, 1870. * Arch. f. klin. Chir., xxvii, 031; and ibid., Ixvi. 

Rev. de Chir., 1911, xliv, .581. e Surg., Gynec. and Obst., i, No. 5, p. 385. 
' Loc. cit. 



421) DISLOCATIONS OF THE SHOULDER 

any attempts at reduction. In 57 cases the bloodvessel lesion was 
discovered after attempts at reduction and complete reduction per- 
formed either immediately after dislocation or a lapse of some time. 
If the cases are considered as to time after dislocation, 31 vascular 
lesions occurred from reduction within three weeks or less, 15 after 
a period of three weeks to two months, and 10 in cases which had 
remained luxated two months to a year. One is likely to consider the 
vascular lesions more frequent after fresh dislocation if the ratio of 
31 to 25 is taken from these figures, but this ratio is absurd when one 
considers the great preponderance of fresh dislocations over old ones. 
The collateral arteries are also wounded. JoesseP made a postmortem 
examination of a recent shoulder dislocation and found the circumflex 
nerve and artery much stretched but not quite torn. Among 13 
cases of rupture of the collateral arteries in Guibe's collection only 
1 was in an old dislocation. In 2 no definite time information was 
given, and 10 were in recent dislocations; 11 cases of injury of the 
axillary branches were noted; 9 were specified; 5 involved the pos- 
terior circumflex, 3 the inferior scapular, and 1 the long thoracic. 

The total lesions are divided as follows: 65 of the axillary artery, 
6 of the axillary vein alone, 6 of both vein and artery. 

To these should be added von Haffner's^ case, in which a man fell, 
dislocated the shoulder and obtained a spontaneous reduction and 
fatal rupture of the artery, and the 2 cases . previously cited by 
Andrews. 

Open dislocation is extremely rare. The accompanying injuries 
and shock are often fatal. Complications of open dislocation consist 
in nerve and bloodvessel injury, immediate thoracic injury involving 
ribs and lung, and the possibility of infection and ankylosis. The 
dislocated head must be cleansed and reduced, with drainage from 
the joint for thirty-six hours. The soft parts are not stitched at all, 
but the wound is left to close with every facility for drainage outward, 
and no retention of discharges under pressure. 

Symptoms and Diagnosis. — In the average case the injured arm is 
held supported by the opposite hand. The elbow stands out from the 
body and cannot be pressed back on account of rigidity and pain, 
and the hand cannot be placed on the opposite shoulder. This failure 
is known as Duga's test. The patient leans toward the affected side. 
Examination reveals that the anterior axillary fold is lower on the 
dislocated side, the long axis of the humerus points more obliquely 
inward than on the opposite side, and the outer aspect of the shoulder 
is flattened. The deltoid seems stretched down tightly over the 
acromion, and its fibers may show fibrillary contractions (Fig. 239). 
Palpation determines the abnormal position of the head anterior to 
and on a le\'el with the glenoid and not in the axilla. There is a cor- 
responding swelling over the head which is recognized by slight rotatory 
manipulation, the motion being felt by the fingers as the bone rolls 

1 Deut. Zeitschr. f. Chir., Bd. xiii. 

2 St. Petersburger Med. Wchnschr., 1911, No. 44, p. 464. 



ANTERIOR DISLOCATIOXS 



421 



beneath. The depression beneath the acromion can be palpated; 
the glenoid is seldom felt. All active motions of the arm are lost, and 
passive motion is painfnl and restricted (Fig. 240). 




Fig. 239. — Subcoracoid dislocation of the humerus. Xote the flattened shoulder, 
lowered axillarj' fold and oblique axis of the humerus. 




Fig. 240. — Subcoracoid dislocation of the humerus. Xote the apparent lengthening j 

of the arm. 1 



422 DISLOCATIONS OF THE SHOULDER 

]\reasiireineiit of the arm's length shows no shortening or a sHght 
longtliening C()nii)are(l to tlie opposite side. There is always an 
apparent lengthening. 

Confnsion in diagnosis can exist only in cases of subluxation and 
fractures of the anatomical and surgical neck of the humerus (which 
see). In the fractures there is generally crepitus and shortening and 
no evidence of anterior luxated position of the head. Dislocation and 
fracture together are very difficult to determine. It is important to 
be sure of the presence of fracture complicating luxation, and every 
diagnostic means must be used to establish the fact in a given case. 
Measurements, crepitus, deformity, and roentgenogram make the 
diagnosis positive. 

Treatment. — Difficulty in reduction of shoulder dislocations is 
explained by a complete understanding of the varying pathology of 
the lesion. In and about the joint itself the interposition of the torn 
capsule, its tight closure about the neck of the bone, a split-off rim 
of cartilage or bone from the glenoid may interfere. When the arm 
drops down, and the head of the humerus is pulled tightly against the 
scapula by the intact outer and posterior portion of the capsule, 
relaxation may be obtained by the attendant's pushing the elbow 
upward before attempting abduction. If this posterior capsular 
portion is torn completely, and the shreds fall over the glenoid surface, 
manipulations of the arm do not disturb them, because their attach- 
ment is severed, and it may be impossible to work them out of the 
way. Anterior dislocation always occurs at the expense of the external 
rotator muscles, which are put on a stretch. Rarely the muscle itself 
is torn, but more frequently, as in all dislocations, the bony insertion 
tends to pull out, and the line of cleavage involves the humerus, par- 
ticularly the greater tuberosity, as we have seen. Its individual facets 
may be detached, the upper, which holds the supraspinatus, or the 
posterior, which holds the infraspinatus and teres minor.^ The bone 
fragments may interfere with reduction, but have not done so in my 
experience unless the luxation is old and a large fragment has retracted 
well up under the acromion. Frequently the fractured tuberosity is 
discovered sometime after reduction of shoulder luxation, when func- 
tion does not return, especially the movements of abduction. The 
biceps tendon, liberated by tuberosity fracture, may block reduction. 
The pull of the unopposed or spastically contracted internal rotators 
of the arm must also be considered as obstacles. Both actual pain 
and fear of pain incite these muscles to powerful contractions to hold 
the bone steadily in its new position. External rotation and abduction 
of the arm overcome most of these obstacles, but in some instances 
these movements will not be permitted by the patient, even when his 
confidence has been gained and his attention is distracted elsewhere. 
In these cases, in order to permit manipulative efforts and to hasten 
the reduction, one may give a general anesthetic. Gas is efficient 

1 Telford, Med. Chron. Manchester, Ix, 218. 



AXTERIOR DISLOCATIONS 



423 



especially with women. For some men surgical anesthesia with ether 
is needed, but in most of them, even alcoholics, the ether rausch gives 
sufficient relaxation. An anesthetic of the degree needed has little 
danger and is preferred to painful and tiresome attempts at traction 
and manipulation. But even with anesthesia shoulder luxations of 
some standing may resist all reasonable efforts by manipulation and 
traction, for the pathological reasons given. In such instances undue 
force must not be used, and the case must be put in the class for open 
reduction. Each case is a law unto itself and must be judged in the 
light of the surgeon's experienced examination. After several weeks 
or even a couple of months the experienced hand may reduce a dis- 
location which had previously resisted all manipulative efforts. 





§^->»^ 




Fig. 241. 



-Kocher's method of reduction of anterior shoulder dislocations, 
performed in the numerical order of the figures. See text. 



The steps 



Methods of Reduction. — A. Manipulation. — This method is that 
described by Kocher^ and consists of manipulation with rotation. The 
untorn and tense portions of the capsule which are stretched over 
the glenoid are relaxed by external rotation of the arm and by eleva- 
tion of the elbow. The tear in the capsule widens, and when the arm 
is fully rotated outward and elevated the head is slipped over the 
glenoid rim and dropped into the glenoid cavity by subsequent internal 
rotation of the arm. The muscular resistance of the subscapularis 
and pectoral is is overconae by steady outward rotation in the first 
-tage of the reduction. When the surgeon masters the method, appre- 
ciates its gentleness and efficiency, and uses it systematically, he 
will find very few uncomplicated cases which are irreducible. 



Bed. klin. Wchnschr., 1870, No. 9. 



424 DISLOCATIONS OF THE SHOULDER 

Kocher's method in detail is as follows: The patient lies on a table; 
the surgeon stands on the injured side (Fig. 241). One hand grasps 
the patient's elbow firmly, while the other holds the wrist with the 
forearm flexed at a right angle. Slowly the arm is rotated outward 
by the surgeon turning the forearm outward. At the same time 
the elbow is pushed upward slightly. If there is obstruction to rota- 
tion and the head of the humerus does not turn outward, the efforts 
must be slowly repeated. This manipulation stretches the sub- 
scapular and pectoral muscles and opens the tear in the capsule. 
The head now rides up on to the glenoid rim and may slip in 
quickly. 

After obtaining rotation the surgeon takes the second step, which 
consists in raising the elbow and arm up across the patient's chest. 
I try to keep in mind that an attempt is being made to approximate 
the point of the elbow to the nipple on the same side. This action 
further rotates the head outward and uses the untorn posterior portion 
of the ligament as a fulcrum for the levering of the head into the 
glenoid. 

The third step consists in the surgeon rotating the arm inward 
by holding the elbow in its elevated position and sweeping the fore- 
arm across the patient's face and letting the arm come to the side in 
a natural position. The important point in the manipulation which 
is often slighted is the elevation of the elbow as high as possible at 
the time of maximum rotation outward. 

B. Traction. — (1) Downward Traction with Leverage. — Downward 
traction with leverage is also a useful method. The dislocated arm, 
which lies in abduction, is pulled downward in the direction of its 
long axis and abduction is made during the traction, while an outward 
pull is exerted on the arm in the axilla by a broad piece of bandage 
or an assistant's fist used as a fulcrum. 

(2) Traction with the Heel in the Axilla. — ^Traction with the heel in 
the axilla is a method like the preceding one in principle. With the 
patient lying on his back, the surgeon grasps the wrist of the dis- 
located arm and makes traction at a right angle, pressing his stockinged 
foot in the axilla for counter-traction and for use as a fulcrum. The 
arm is slowly adducted during the pull. This method is dangerous, 
inasmuch as great force can be exerted by the weight and swing inward 
of the surgeon's body during the traction. The surgical neck of the 
humerus may be broken. I have seen that accident occur. Vessels 
and nerves may be torn or avulsed by the direct traction or the press- 
ure of the heel in the axilla. The method does not take the local 
pathological conditions into consideration, and there is no rotation 
outward to open the capsule. Reductions can be made in this way, 
but it is more painful and dangerous than Kocher's method and has 
no compensating advantage over it. When reduction fails, the surgeon 
is likely to exert too much force and cause injury, so that the method 
should not be used as a routine, but only in cases of failure by man- 
ipulation. 



ANTERIOR DISLOCATIONS 425 

(3) Direct Reduction. — Direct reduction is useful when the capsular 
tear is extensive or there is merely a subluxation. The arm is held 
in slight abduction, the patient standing or sitting, and the elbow is 
pressed up. The surgeon makes direct pressure on the head of the 
bone to force it back into the glenoid. A hand may be slipped into 
the axilla for direct pull on the upper end of the humerus outward and 
backward, while the other hand steadies the scapula. 

(4) Downward and Outward Traction. — Dow^nward and outward 
traction can be employed in two ways. The first consists in the fixing 
of the patient in bed by counter-extension applied by a broad band 
around the chest. The dislocated arm is grasped, pulled outward 
with or without the heel in the axilla, and at the same time rotated 
outward. The head of the humerus is watched for the change of posi- 
tion denoting its approach toward the glenoid, and when it has 
descended may be pressed down into the cavity by an assistant, while 
the surgeon brings the arm to the side. Instead of placing the heel in 
the axilla the surgeon may place the patient on the fioor and use both 
feet, one against the chest and the other against the acromion, draw- 
ing the arm directly outward. Stimson has modified this method 
by using a canvas cot with a sixteen-inch hole at a point where a 
man's shoulder would lie. The patient lies on the cot, and to his 
luxated arm projecting through the hole toward the fioor is hung from 
the wrist a weight of about ten pounds. Reduction takes place quietly 
and painlessly in a few minutes. 

(5) Upward Traction.' — Upward traction is seldom used in anterior 
dislocations, its greatest use being in subglenoid or erect dislocation. 
Direct pull upward is made by the surgeon grasping the wrist, 
counter pressure being exerted against the acromion by the heel or 
pull of an assistant, and the arm, gradually swung outward and let 
down, is lifted into normal position. The method really corresponds 
to outward traction, because the relation of the arm and scapula do 
not change after abduction and elevation to a right angle are obtained. 
Further movements upward are only by rotation of the scapula on the 
chest. There are many modifications of this plan, the easiest of 
application being that of Malgaigne, who fastened a band about the 
patient's wrist, had him stand near a door, and by passing the end of 
the band over the door top made traction upward on the arm until 
the dislocation was reduced. 

Operative Treatment. — Operative treatment is seldom necessary in 
recent cases, except in the few irreducible ones or those complicated 
by fracture and injury of other structures. It is discussed under the 
>iibject of Old Dislocations. 

Treatment after Reduction. — After reduction the joint must be held 
in a position of rest until its structures are healed and the surrounding 
muscles regain tone. This requires two to three weeks' immobiliza- 
ti(/n. For the arm to be held in a position which favors healing of 
a tear in the anterior portion of the capsule the humerus must be 
rotated inwarrl and the head should point outwanL This position 



426 DISLOCATIONS OF THE SHOULDER 

is secured by a bandage or dressing which holds the elbow in against 
the front of the chest and the forearm rotated in to permit .the hand 
to lie either on the opposite shoulder or across the upper part of the 
opposite side of the chest. The dressing may consist of a broad piece 
of adhesive plaster applied like the second part of the Sayre's dress- 
ing for fracture of the clavicle, or it may be a few turns of plaster 
of Paris over a cotton bandage. Cotton^ uses a band of adhesive 
passed around the arm and across the chest in front to hold the arm 
steadily in and a separate muslin sling to suspend the forearm from 
the neck. Danielsen^ advises a position in which the arm is placed 
alongside the cheek and the forearm is flexed over the head, the whole 
encased in plaster of Paris to promote a maximum relaxation of the 
muscles about the joint and an approximation of the torn capsule. 
Braatz^ admits the physiological correctness of the position, but 
believes that it is irksome to the patient and advises that the same 
position can be secured by the shoulder being pressed well forward 
and fixed firmly by a strap of adhesive which extends on the chest 
wall in front. 

After two or three weeks the bandages are removed, and the arm 
is massaged daily, the forearm hanging in a sling for ten days longer. 
Active and passive movements are controlled by the pain they cause, 
no painful motion being permitted. The patient is warned to avoid 
movements which rotate the arm outward or abduct it, such as those 
involved in putting on coats or shirts. 

The results vary with the individual injured and probably also 
with the extent of the pathology. The ecchymoses about the joint 
and down the arm may be weeks in absorbing. Swelling is not great, 
and the motion of the shoulder-joint gradually returns to normal in 
most cases. There is tenderness in the joint for some time, although 
I have frequently seen laboring men who had suffered a traumatic 
shoulder dislocation able to use their arms in any manner in three 
weeks with no complaint of pain or weakness. Young adults usually 
recover quickly. In older people the immobilization alone may lead 
to stiffness and restriction of motion. Those with a tendency to gout 
or osteo-arthritis are likely to find restricted shoulder motion after 
two weeks' immobilization. There may also be lime deposits made 
in the periarthritic tissues.^ Recurrences of uncomplicated disloca- 
tion are rare, especially if they are accorded proper reduction and 
after-treatment. (See Subluxation and Recurrent Dislocations.) 

The complicated cases do not fare well. We have seen that the 
mortality following vascular lesion is very high in spite of all treat- 
ment. The lesions of nerves vary in result according to their character. 
Contusion and stretching with no loss of neurone continuity give a 
favorable prognosis, avulsion of a single nerve or trunk of the plexus 

1 Joint Fractures and Dislocations, p. 168. 

2 Zentralbl. f. Chir., Leipzig, 1914, xii, No. 41. 

3 Ibid., p. 1673. 

* Wrede, Arch. f. klin. Chir., Berlin, xcix. No. 1. 



ANTERIOR DISLOCATIOXS 



42: 



offers no hope, in spite of massage and electricity, until operation 
and plastic repair is attempted. Tearing out of the tuberosities, 
laceration of the spinati and subscapular muscles or their insertions, 
lead to permanent restrictions of shoulder motions. Abduction 
becomes almost nil when the tuberosities are loose, and the joint 
may lock from the presence of a loose fragment. Dislocation com- 
plicated by fracture of the humerus at the neck may give a fair result 
even when unreduced. The question of old unreduced dislocations is 
considered separately. 

Subluxations. — Subluxations forward are not common, but they 
are puzzling on account of the physical findings and the lack of func- 
tional use of the joint. A primary uncomplicated traumatic subluxa- 




FiG. 242. — Old subluxation forward of the humerus. The head lies on the anterior 
lip of the glenoid, the greater tuberosity has been avulsed and there is callus formation. 
Note the flattened shoulder from long disuse of the deltoid. 

tion is not a definitely accepted clinical entity, but I believe it does 
occur. In the last eighteen months I have seen two cases which 
would come under this classification (see Fig. 242). Malgaigne^ 
referred to incomplete anterior dislocation. Stimson and Hamilton 
believe it occurs. Subdeltoid bursitis or dislocated long head of the 
biceps tendon may simulate it. Primary cases are probably caused 
by direct violence on the shoulder, and some of the subluxatious 
undoubtedly result from incomplete reductions of primary subcora- 
coid dislocations. The head seems to bulge and to rest slightly forward 
compared to the opposite shoulder. There may be some flattening 



1 Traite des Frar-t. et des Luxatif)ri.s, Paris, lH.5o. 



42S DISLOCATIONS OF THE SHOULDER 

on the posterior aspect of the joint, and motions are restricted and 
ma>' be i)ainful. The deltoid contour usually shows no changes. 

The change in the relation of the humeral head to the articulating 
glenoid surface consists in a slight advancement of the position of 
the head, so that it probably rests on the glenoid rim. The capsule 
may be torn anteriorly or simply stretched. Why the head should 
come to rest in this anterior position is a difficult matter to determine. 
Some of the reported cases have had accompanying pathology which 
might account for the subluxation. South reported a case verified by 
autopsy. There was a small capsular tear, also a fracture of the 
coracoid, acromion and clavicle, and the head rested on the anterior 
glenoid margin. Other instances have been recorded by Hargrave, 
Petit, Dupuytren and Astley Cooper. Cooper had 2 cases and 
dissected a third in which he found the tendon of the long head of 
the biceps ruptured and the humeral head lying below the coracoid, 
having formed a new articular surface on the neck of the scapula. 
One case in which the periosteum on the anterior surface of the neck 
was stripped up was reported by Broca and Hartmann.^ The capsule 
was intact but the anterior half of the interarticular cartilage was 
torn loose. Russ^ reported 7 cases of subluxation seen in a period 
of from two days to six months after accident. Vale^ reported a trau- 
matic subluxation accompanied by subluxation of the acromial end 
of the clavicle. Since then Miriel^ has added 5 cases and Brickner*^ 
3 cases. Brickner found that abduction of the shoulder was limited 
and painful, but that inward rotation was normal, so that the patient 
could put the hand up behind the back. When the arm was abducted 
to a horizontal position, the prominence of the humeral head disap- 
peared, and the patient could then continue the abduction unaided. 
After the arm was lowered the deformity and pain reappeared. Dif- 
ferential diagnosis must exclude tumor or osteomyelitis of the upper 
end of the humerus, dislocation of the biceps tendon, and various 
arthritides. 

Treatment. — ^Treatment consists in complete reduction by Kocher's 
method or by a holding of the arm in abduction for two weeks (Brickner 
advises 135 degrees). I operated on 1 case and found no dislocated 
biceps tendon, but a slight mashing and overgrouth of the glenoid 
rim. This was removed, and the capsule was stitched on the anterior 
surface, but the reposition was not perfect, as shown in stereoscopic 
roentgenogram. 

Intracoracoid and Subclavicular Dislocation. — ^As previously men- 
tioned, this form of shoulder luxation implies that the head of the 
humerus lies farther inside of the coracoid line than the subcoracoid 
type. The differentiation is purely artificial, and until the head of 
the bone leaves the coracoid area altogether and lies under the clavicle, 

1 Bull. Soc. Anat. de Paris, 1890, Ixv, 312. 

2 Surg., Gynec. and Obst., 1909, viii. 

3 Washington Med. Ann., 1908, vii, 5. 

^ Gaz. des Hop, Paris, 1912, Ixxxv, 1307. 
'" Am. Jour. Surg., 1915, xxix, 50. 



POSTERIOR DISLOCATIONS 429 

the luxation might still be termed subcoracoid. Considering the 
wider displacement, one expects more pathology than in a subcoracoid 
about the luxated head. The capsule is more widely torn. There is 
more swelling and a greater violence has acted. This displacement 
results also in tearing off of the bony surfaces of the tuberosities, 
laceration of the subscapularis muscle, and greater pressure on the 
contents of the axilla. The arm is in a position of greater abduction, 
the head of the humerus lies higher and farther in toward the median 
line immediately beneath or even behind the clavicle. Beneath the 
acromion there is a more prominent hollow and the arm is shortened. 
AVhen the arm is abducted, the shoulder sticks and the movements 
obtained include the scapula. In some rare instances the arm remains 
abducted after the luxation, and the head is driven forward and inward 
so that the arm stands out widely. 

Treatment. — Treatment of this type of dislocation is reduction by 
the different means used for subcoracoid luxation. If the displace- 
ment is distinctly subclavicular and the head lies far inward and is 
rigidly bound in slight inward rotation, it is wise to make lateral and 
downward traction on the arm in order to pull the head out until it 
comes to rest under the coracoid. This traction may be continued 
until reduction occurs, especially if the ligaments have been widely 
torn. After a subcoracoid position is reached and the ligaments and 
capsule appear not to be torn more than in an ordinary case, any of 
the maneuvers of reduction will effect a replacement. 



2. POSTERIOR DISLOCATIONS. 

These are classified as subacromial and subspinous, depending on 
the position the head assumes in relation to the acromion process and 
spine of the scapula. As in the case of the anterior dislocations, the 
division is quite arbitrary, except in the rare instances of complete 
su'bspinous displacement. Posterior traumatic dislocations are 
uncommon; a few of them occur in infants at time of delivery, or are 
congenital in character. Hitzrot^ recorded a case in an eight-year-old 
girl. 

The causes are usually falls on the elbOw with the arm adducted, 
muscular action, or direct violence from a blow against the front of 
the shoulder. The mechanism is first internal rotation of the arm and 
humeral head, then tearing of the posterior portion of the capsule, 
and continuation of the pressure, forcing the bone head out posteriorly . 
Many cases occur during epileptic fits from muscular contraction or 
falls. Malgaigne collected over .30 cases in 1855, and there have 
been about 20 more added to the literature since that time. vSome 
of the cases have permitted careful examination, as the patients 
suffered other and fatal injuries. 

» Ann. of Surg., Iv, G22. 



430 DISLOCATIONS OF THE SHOULDER 

Pathology. — The pathology involves the capsular ligament, which 
has been rather widely torn in all cases examined. The greater tuber- 
osity of the humerus has frequently been avulsed, remaining near its 
normal position. The subscapularis muscle and lesser tuberosity 
have been found torn off, and the long head of the biceps may be 
displaced from its groove and come to lie on the axillary side of the 
bone, as in Hitzrot's case. The spinati muscles are usually unharmed. 
Fracture of the humeral neck may be a complication. 

Symptoms. — The arm has generally been found rotated inward and 
adducted so that the elbow presses against the side of the chest wall. 
x\rm movements are painful and restricted. The length of the arm 
does not vary enough to be of any value for diagnosis. Examination 
of the shoulder shows swelling, which may mask the position of the 
head. The front of the joint seems flattened, the acromion is promi- 
nent, and pressure over the anterior surface of the shoulder fails to 
feel the round head of the humerus. On the back of the joint there 
is swelling, and the head can be felt to rotate with the shaft. Sub- 
acromial dislocations are likely to be overlooked, much as subluxations 
forward, and both shoulders must be compared. The long axis of the 
humerus may be directed backward enough to be of aid in diagnosis. 
In the subspinous variety, the head has moved well backward and 
inward and has dropped away from the acromion to such an extent 
that a finger may be pressed in between them. The joint in front is 
strikingly empty, and the arm may be in abduction and internal 
rotation. 

Prognosis. — The prognosis of the subacromial type is good, as reduc- 
tion is easy. The cases which are overlooked on account of swelling 
may be difficult to replace, and function can be greatly limited if 
reduction is not prompt. Muscle and capsular lesions heal readily. 
The diagnosis must consider bursitis and sprains or contusions about 
the shoulder-joint. The fulness of the shoulder posteriorly and the 
disappearance of such fulness after reduction efforts confirms diag- 
nosis. Roentgenograms of both shoulders in corresponding positions 
will aid materially. 

Treatment. — ^Treatment is accomplished by traction on the arm 
down and outward, accompanied by slight rotary motions to open 
the capsular tear. Direct pressure on the head by the thumbs of an 
assistant may push the head forward into the glenoid. After the 
arm is pulled downward it can be adducted and rotated inward for 
the relaxation of the intact anterior position of the capsule and the 
attached muscles, the head being levered thus gently back into the 
glenoid. Recurrence after simple traumatic posterior dislocation 
should not be more frequent than after anterior dislocation. If there 
is complicating pathology involving fractures of the tuberosity or 
glenoid rim and muscle laceration, reduction may be incomplete, and 
if function is interfered with, open operation will be indicated. One 
must consider the possibility of permanent cure very carefully before 
operating on epileptic or paralytic cases who lack muscle tone. 



DOWNWARD DISLOCATIONS 431 

3. DOWNWARD DISLOCATIONS. 

Downward dislocations are divided into subglenoid and luxatio 
erecta. 

Subglenoid Dislocations. — Subglenoid dislocations comprise those 
in which the head of the humerus has been displaced downward on 
the tendon of the long head of the biceps muscle or has assumed 
a position beneath the glenoid rim and lies on the under surface of 
the scapular neck. This position, considered as a permanent displace- 
ment, is uncommon, but it doubtless occurs frequently in the course 
of what finally becomes a subcoracoid dislocation. 

Cause. — ^The cause is hyperabduction of the shoulder by the indi- 
vidual raising his arm forcibly, as in raising a person by a violent jerk 
on the arm, or by his falling into a narrow space with the arm extended. 
Pitching falls on the extended arm offer the same mechanism. The 
capsular tear is in the lower border between the subscapular inser- 
tion in the lesser tuberosity and the biceps head. The subscapular 
muscle is generally torn. In Leroy's case^ the capsule was torn on the 
lower internal border along the edge of the glenoid and was also 
separated at the upper part, including the insertion of the spinati 
muscles. The head of the humerus rested on the axillary border of 
the scapula and was so rotated that the greater tuberosity rested 
against the anterior border of the neck of the scapula. The sub- 
scapular artery and the circumflex artery and nerve may be injured. 
In all the cases I have seen there has been a complicating fracture of 
the greater tuberosity. 

Symptoms and Diagnosis. — The arm is more abducted and appears 
shorter than in subcoracoid dislocation. The difference in length 
of the two arms may be but little by mensuration. The long axis 
of the humerus prolonged passes through the upper part of the chest 
and does not point up into the neck so acutely. The humeral head 
lies in continuity with the shaft and can be felt and seen bulging out 
the axilla. There is flattening of the deltoid area and a palpable 
hiatus exists between the acromion and the head. As in types of 
forward dislocation the differentiation between subglenoid and sub- 
coracoid luxations may be merely a matter of slight difference in posi- 
tion of the head. In the true subglenoid type the head lies in the 
axilla behind the border of the pectoralis major and not under it. 

Treatment. — Treatment is traction outward and slightly upward, 
with some external rotation to open the capsular tear. This action 
lifts the head on to the glenoid, and by the arm being swung it can 
be levered into position. Direct pressure upward on the head during 
traction may push it quickly into place. Any of the methods for sub- 
coracoid dislocation may be used, especially if in the manipulation 
the head rides farther forward and tends to assume a subcoracoid 
displacement. Fracture of the tuberosity must be excluded after 
reduction, and a roentgenogram should be made. 

» Bull, de la Soc. Anat., 1844, p. 102. 



432 



DISLOCATIONS OF THE SHOULDER 



Luxatio Erecta. — This is an unusual and excessive type of sub- 
s:lcnoid dislocation, caused by forcible abduction of the arm and 
possibly by additional force which pushes the head downward after 
it is pried out of the shoulder cavity. The arm is completely elevated, 
the forearm rests across the head and there is pain and rigidity on 
all attempts to lower it. There is great capsular damage, with asso- 
ciated muscle tears. Fracture of the tuberosities, injury of the axillary 
vessels and nerves, and the circumflex nerve and artery are expected. 
Diagnosis is not difficult. The arm is held rigidly up, the head of 
the bone can be felt in the axilla, and there is no fracture of the 
humerus. The acromion may be broken off from pressure of the 
humerus as the displacement occurs. I have seen one case in which 
the humerus was broken at the surgical neck after the head was in a 
position of extreme subglenoid dislocation; the arm fell to the side, 
leaving the head out of the joint turned upside down. There was 
shortening of the arm and much pressure pain. Diagnosis was made 
from the roentgenogram. 

Reduction is made by traction upward to pull the head back into 
the glenoid via the tear in the capsule on the lower border. Direct 
pressure upward on the head is of assistance. The arm is then lowered 
to the side by adduction. 



4. UPWARD DISLOCATIONS. 



Upward dislocation, when the head lies in a supraglenoid position, 
is extremely rare. Stimson^ has collected 14 cases starting with 
the first case reported by Laugier^ in 1834. The recent literature 
of dislocations has been barren of this type, and on account of its 
rarity and the disputed true character of most of the reported instances, 
only the essential points will be discussed. The cause is probably 
extreme violence directed against the arm in an upward and forward 
direction, possibly applied at the elbow with the forearm in flexion. 

The humerus is displaced upward and forward. Capsular lesion 
must occur on the upper margin, and if the displacement is great the 
whole capsule and the periosteum about the neck may be stripped 
off. Fracture of the acromion, coracoid, greater and lesser humeral 
tuberosities, and even of the clavicle may be complications. The 
long head of the biceps tendon is either torn from its insertion at the 
top of the glenoid rim or it remains adherent, and the head rides 
forward and upward, leaving the tendon on its inner surface below. 
Experiments on the cadaver show that outward rotation of the arm 
accompanied by an upward driving force can produce the dislocation. 
The deltoid fibers may be separated, the head forcing its way through 
them. Muscles attached to the tuberosities may be lacerated or torn 
loose from the bone. 

' Fractures and Dislocations, 7th edit., p. 651. 
2 Arch. Gen. de. Med., 1834, x, 35. 



UPWARD DISLOCATIONS 433 

Symptoms and Diagnosis. — The head of the bone is plainly seen rid- 
ing upward and may project an inch above the acromion. Rotatory 
shaft movements cause this head to move, and the arm is shortened. 
Posteriorly the shoulder appears flattened, and the deltoid fibers 
may be relaxed, if the bone has punctured through them. The 
coracoid and acromion cannot be satisfactorily palpated. Shoulder 
movements are restricted and painful, and the arm lies close to the 
side. 

Treatment. — Practically all the cases reported have been old cases 
in which traction failed to effect reduction. In recent cases, one of 
as long standing as thirty days, traction downward aided by direct 
pressiu-e on the head has made reduction. Some of the long-standing 
cases were given no treatment. In the hands of modern surgeons open 
operation would undoubtedly be performed to free the head of the 
bone, hollow out the glenoid and cover its surface with a fat or fascial 
flap for arthroplastic purposes. A simpler operation would consist 
in excision of the head and a covering of the neck with a tissue flap 
to form a false joint at the site of the old glenoid cavity. The deform- 
ity alone would hardly constitute an indication for open operation, 
if the function were at all satisfactory. A painful and stiffened arm 
bound close to the side would surely be mobilized in the present 
era of joint surgery. 

Habitual and Recurrent Dislocations. — Recurrent shoulder dis- 
locations which become habitual are not common. They are practically 
all of the anterior type. They occur frequently in epileptics who are 
subject to falls in convulsions and have suffered one or more traumatic 
dislocations. 

Causes. — The causes are assigned to three different sources, or a 
combination of them, by most authors. In 1886 Lobker called 
attention to anatomical defects in the shape of the head of the humerus 
which were like compression grooves, and which were supposed to 
permit the head to slide easily over the glenoid ring. The bone defect 
in the humerus by groove, or the tearing of the tuberosities and bone 
avulsion of the glenoid rim, comprise one class of causes. Two other 
conditions favoring recurrence are supposed to be laxity or incom- 
plete healing of the capsule, and tearing or atrophy of those muscles 
which act to hold the humerus up against the glenoid and so tend to 
prevent dislocation (external rotators). 

(I) Bone Defects. — Lobker's specimen showed a deep groove in the 
head in a part of its circumference which rested next to the glenoid. 
The cartilage over this depression was smooth and showed no injury, 
nor was there evidence of compression fracture of the bone at that 
site. 

Gregoire^ made an anatomical study of the head of the humerus 
in recurrent dislocation and stated that he considered the groove or 
notch present in the humeral head was the main cause of habitual 

1 Rev. d'Orthop., January, 1913. 

28 



434 DISLOCATIONS OF THE SHOULDER 

dislocation and that the deformity was a congenital one antedating 
the first dislocation. Laxity or attenuation of the capsule practically 
always accompanies this bone deformity. He attempted to prove his 
assertion by studying the internal arrangement of the trabeculse in 
the head. In recurring dislocations, he found a regular trabecular 
arrangement as in the normal head, contrasting with the irregular 
distortion of trabeculse in old unreduced dislocations, which also present 
this type of groove or notch. When the inner edge of the glenoid has 
been chipped or torn away, we may expect dislocation to occur more 
easily, but this defect has less importance in the causation of habitual 
dislocation than it has in subluxation. If the notch in the bone and 
a weakened capsule are the main causes, the recurrent mechanism is 
explained on the basis of elevation of the abducted arm with external 
rotation. The capsule yields in front, the notch locks over the anterior 
border of the glenoid rim, and a slight trauma is sufficient to force 
the dislocation on to completion. 

(2) Laxity. — Laxity and incomplete healing of the fibrous portion 
of the joint capsule, with or without head abnormalities, is given as 
a principal cause. Thomas^ is of the opinion that recurrent luxation 
is exclusively caused by capsule laxity and that the condition is a 
hernia of the joint, a thinning of the fibrous portion, permitting a 
bulging weakness of the synovial portion like a sac. 

(3) Atrophy or Tearing of the External Rotators. — ^Atrophy or tear- 
ing of the external rotators of the shoulder and the shoulder-girdle 
muscles is also considered a main cause. The most recent champion 
of this factor is Selig,^ who considers it of superior importance over 
bone deformity, glenoid injury, and looseness of the capsule. 

Probably no one pathological group of conditions can be made to 
cover all cases. The observations of all operators who have reported 
cases must be put together, and the results they have obtained must 
be sifted until conclusion can be reached as to the cause of most of 
the cases and the procedure which will effect cure in the majority. 
An extensive capsule laceration which has never been properly healed, 
a laxity of the whole capsule of long standing, rupture or atrophy 
of the external rotators of the humerus, and fracture of the glenoid 
rim or other bone defects previously enumerated, may be present in 
any combination. 

Treatment. — The simplest treatment of habitual dislocation con- 
sists in the avoiding of recurrence. That means avoidance of abduction 
and elevation of the arm, for some cases slip out of place so easily that 
the act of putting on a coat or raising the hand to the head is suffi- 
cient to produce luxation. Recurrence can be warded off by the 
patient's wearing a stiff shoulder cap which inhibits abduction and 
elevation, or by wearing about the wrist a strap which is fastened 
to the waist affording enough play for some uses, but prohibiting 
the dangerous positions. Reduction after habitu'al dislocation is 

1 Surg., Gynec. and Obst., 1914, xviii, 107; Am. Jour. Med. Sci., February, 1909. 

2 Deutsch. Ztschr. f. Chir., Leipzig, 1915, cxxxii, 581. 



UPWARD DISLOCATIONS 435 

generally easy to perform. Sometimes the patient can do it himself 
or can direct others with little pain to himself. A few persons can 
cause both a dislocation and its reduction by muscular action, and the 
act can be repeated any number of times. Usually the intervals 
between luxation are variable and dependent on thoughtless move- 
ments or slight accidental trauma. Rarely the fear of pain of reduction 
on the part of patients necessitates the use of anesthesia. 

Operative treatment offers hope of much improvement and probable 
cure, and the condition cannot be made worse. Operations repair 
the pathology as- it is fomid or simply make an ordinary capsular 
replacement with or without strengthening it. Hildebrand reported 
25 operative cases^ and Perthes 4.^ In their operations they deepened 
the glenoid cavity when it was found to be shallow, packed pouches 
in the capsule with gauze and reattached the external rotators to the 
tuberosity, or tucked the capsule as indicated. 

Thomas^ is a firm advocate of capsule plication (capsulorrhaphy), 
basing his opinion on the fact that bony contact between the humerus 
and the glenoid cavity is maintained at all times in a normal shoulder 
in any position. His report covers eighteen shoulders operated on 
in sixteen patients and after his preliminary work on the cadaver he 
now advises the axillary operation. He performed twelve out of 
eighteen operations by an axillary incision anterior to the large vessels 
and nerves. Two successful cases done by this approach were reported 
by Telford."^ Thomas now offers the posterior axillary operation as 
a simpler procedure, the time for completing it being but from twenty 
to thirty minutes. The arm is held out at right angles to the body, 
and a four-inch incision posterior to the axillary vessels is made over 
the head of the humerus. The latissimus dorsi tendon is the guide 
at the bottom of the wound. This tendon is retracted downward, 
and the subscapular muscle is pulled upward and freed from the 
capsule which lies just beneath. The circumflex nerve and artery 
are identified and isolated. Palpation of the glenoid and head of the 
humerus shows the extent of the capsule, which is then cut open from 
the top to the bottom midway between the glenoid and humeral 
attachments. If necessary, the head of the bone can be inspected or 
loose bone fragments can be removed. The head is placed in the 
glenc»id, and the capsule is overlapped and sutured without too much 
tension. Drainage is instituted by means of a rubber tube, which is 
removed the next day. The skin is sutured and the arm is bandaged 
to the side with an aseptic axillary pad. This becomes saturated and 
needs daily renewal. After three weeks a non-epileptic patient begins 
movements upward anteriorly, which he increases until after five 
weeks he is urged to climb a hanging rope or hang from a horizontal 
bar, and the shoulder movements rapidly become normal. Kpilei)ti(' 
patients are kept quiet at least four weeks before motion is permitted. 
Thomas states the following advantages of the posterior axillary open- 

' Arch. f. klin. Chir., Ixvi, 300. 2 Deutsch. Ztschr. f. ("hir., Ixxxv, 199. 

» Loc. cit. •« Lancet, Loudon, August 3, 1912. 



436 DISLOCATIONS OF THE SHOULDER 

ing over the anterior: It makes a smaller wound, the large axillary 
vessels and nerves do not come into view, and the anterior circumflex 
vessels are not injured as they are in the anterior operation. Capsular 
access is easier and more rapid. Time of operation is shorter, normal 
motion returns more quickly, and there is less buried suture material. 

The results of capsulorrhaphy are very encouraging. Of Thomas's 
18 operations, 16 were successful, 1 partially successful, and 1 a failure. 
The earlier this operation is performed, the better the chance of cure. 
Non-epileptics offer a better prognosis than epileptics, and the failures 
in late cases are probably caused by the groove defects in the head of 
the humerus or the glenoid and the great laxity of tissues afforded by 
the repeated luxations. 

Other methods to strengthen the weakened capsule in addition to 
capsulorrhaphy have been used. Wernsdorff^ advised open operation 
on all habitual shoulder dislocations, but, because he believed capsular 
plication alone was insufficient, he took the short head of the biceps 
and fastened it to the lesser tuberosity to strengthen the active restrain- 
ing apparatus in front of the joint. Openshaw reported 3 cases suc- 
cessfully treated after failure by other methods, by detaching the 
subscapularis tendon from its insertion and fastening it to the anterior 
edge of the deltoid muscle. Ehrlich and Clairmont^ took a flap of 
deltoid muscle from the posterior border which they swung under the 
anterior aspect of the shoulder to strengthen the capsule. They did 
4 cases with a recurrence in 1. Armour^ in a report on Clair- 
mont's operation states that Robert Jones had performed two of these 
operations in 1912. The flap of deltoid muscle is carried through 
the quadrilateral axillary space from behind forward and so fastened 
in front that it makes a sphincter-like ring about the neck of the 
humerus. The subsequent immobilization of the arm must continue 
at least two months. The first case operated on by Jones recurred 
after the dressing was removed, the . cause being either insufficient 
fixation of the muscle or too short an immobilization. The second case 
obtained a cure. SeideP separated the subscapular muscle, took out 
an oval piece of the capsule, sutured the edges together, and then 
covered the entire front of the joint with a piece of transplanted fascia 
which he sutured to the deltoid and subscapularis. The patient 
died some time later, and microscopic examination showed that the 
fascial flap had been preserved. Schultze^ reported 26 cases of habitual 
shoulder luxation treated by capsule plication, 7 of which recurred 
within two or three years. He has come to agree with others who 
believe that fascial flaps are necessary in addition to the capsule 
suture. 

The influence of the muscles has attracted Selig's attention.^ He 

1 Ztschr. f. Orthop. Chir., 1908. 

2 Freie Vereinig der Chir. des Congress, Sachsen, 1913. 

3 Liverpool Med. Chir. Jour., 1914, xxxiv, No. 65, p. 100. 

4 Zentralbl. f. Chir., 1913, xl, 1344. 

B Arch. f. klin. Chir., 1914, Bd. civ, Heft 155, p. 139. 
« Loc. cit. 



UPWARD DISLOCATIONS 437 

criticizes the use of inactive tissue like fascia or the biceps tendon 
to strengthen the capsule, and says recurrences can be avoided by 
using active instead of passive material. Ducherne^ is quoted as 
stating that the supraspinatus muscle is an elevator of the arm more 
powerful than is understood, and besides helping the deltoid it also 
aids in holding the head of the humerus in contact with the joint 
surface. When the supraspinatus and trapezius have atrophied, dur- 
ing a subsequent raising of the arm the head of the humerus is fre- 
quently displaced forward into subluxation. If the surpraspinatus 
is functionating normally, even when the deltoid is atrophied, the 
subluxation cannot occur. The scapulohumeral ligament is important 
in this restraint. Selig advocates an open operation also on an anatomi- 
cal basis from his standpoint, namely, through an incision in the 
supraspinous fossa. The trapezius fibers are separated, and the 
supraspinatus tendon is recognized. This tendon is shortened by 
plication as much as it can be, and the dislocation does not recur, 
because the muscle holds the humeral head in place. 

Recurrent and habitual dislocations dependent on pathological joint 
changes, congenital conditions and paralyses, and not the result of 
traumatic dislocation are not considered in this work. 

Old Shoulder Dislocations. — Shoulder dislocations become old at 
different periods following their luxation. Some can be reduced a 
month after injury, others have been put back after four months, but 
as a rule after three months of displacement in the abnormal position 
the dislocation becomes irreducible and is classed as old. Kocher 
considers them irreducible and subject for operative reduction as early 
as five to seven weeks after luxation, yet he reports 25 out of 28 
cases reduced by manipulation, 1 over five months after injury .^ 

The obstacles to reduction may comprise any one or a combina- 
tion of those given under obstacles to recent dislocation. There are 
in addition the secondary and progressive changes of the displace- 
ment. Briefly there are cicatricial contractions of healing scars in 
the capsule, adhesions to surrounding axillary structures, bone frag- 
ments, osteophytic outgrowths, callus within the glenoid, or over- 
growth of the glenoid rim. The muscles about the shoulder become 
shortened, adherent and atrophied and obstruct replacement. A 
new glenoid cavity with a false joint and considerable function may 
Have developed, and the question arises whether it is better to attempt 
to restore the head to its customary position and expose the patient 
to operative risks and possible sepsis with a resulting ankylosis, or 
to leave the condition as it is. When the arm is rigidly fixed and 
there are pressure symptoms on axillary structures, the problem 
becomes one of deciding between excision of the head and a false joint, 
osteotomy through the neck with a false joint, or better position of 
the arm and operative replacement. 

Xon-operative replacement must be tried. The operator must 

1 PhysioloKie der Bewegungen, Kassel, 1885, S. 61. 

2 Deutsch. Ztschr. f. Chir., 1911, xliv, 581. 



438 DISLOCATIONS OF THE SHOULDER 

bear in niiiid the daiifijers of rupture of axillary vessels and nerves, 
as well as fracture of the humerus. In the cases reduced by Kocher 
spoken of previously, the humerus was fractured three times. Mr. 
Robert Jones uses padded iron rings through which the arm is carried, 
and traction is made with counter-extension of the ring against the 
scapula and axilla. He has two rings, one arranged for the patient 
to sit and the other for him to recline under anesthesia. Thomas^ 
prefers the older method of traction in abduction and reports 5 
cases. He failed to obtain reduction on one side of an old double 
dislocation. His method is similar to that employed by Jones, but 
instead of using a firmly fixed and padded metal ring for counter- 
traction, he steadies the scapula by bracing his feet against it. The 
abduction method depends largely on the strength of the humerus 
and the firm scapular fixation, force being applied directly to the 
shortened portions of the capsule by the traction made in the long 
axis of the arm. The patient is fully anesthetized by ether, placed 
on the floor, the arm manipulated slightly to tear the contracted 
capsule, and traction is made on the arm by Allis^s apparatus. The 
operator braces one foot against the axillary border of the scapula and 
the other against the acromion and upper border while he pulls in 
abduction. As the head starts to descend an assistant may aid by 
pushing down on it. Old dislocations are characterized by a head 
lying higher than that in recent luxations. The traction in the humeral 
axis avoids torsion strains and fracture, but it brings the head down 
near the glenoid level, so that it can be pushed or levered over the 
edge into the joint. As the pull overcomes the resistance and the 
head reaches the position near the glenoid the assistant makes pressure 
outward and backward to force the head over into the joint. Once 
into the joint the elbow is also pulled upon by the assistant to assure 
complete reposition while the operator maintains his traction. The 
indications for attempted reduction of old dislocations, especially 
by operative means, can be enumerated as (1) pressure symptoms on 
nerve and vascular structures and (2) cosmetic and functional better- 
ment. If the head is restored to a normal locus, even if the joint is 
stiff, the scapula permits considerable movement, and muscular 
atrophy and disfigurement may be overcome. The incisions are 
anterior by Andrew's and Jonas's method; axillary by those of Langen- 
beck, Madelung, and Nelaton. The anterior incision offers the most 
complete and easiest approach to the restricting tissues, the axillary 
is efficient for resection of the head, but like the posterior incision 
it does not permit approach to the adherent anterior part of the 
capsule in the upper anterior axillary space, and it offers little chance 
for leverage on the head of the bone. A posterior approach also 
involves division of the scapular spine and reflection of the acromion. 

Dollinger, of Budapest, in his first report in 1902,^ mentioned 19 
old shoulder dislocations treated in five years. Six were treated by 

1 Ann. of Surg., Ivii, 217. 

2 Deutsch. Ztschr. f. Chir., Ixvi, 319. 



UPWABD DISLOCATIONS 439 

non-operative method, 2 resulting in fracture of the neck of the bone 
with no reduction. Of the remaining 13, 3 were treated by resection 
of the head, and 10 open arthrotomies were done to cut the retracted 
subscapularis muscle, which he considered the greatest obstacle to 
reduction. In 191 P he made report on 39 operated cases, 33 of which 
were treated consistently by division of the subscapularis. Eight of 
these cases were infected, and there was 1 death from injury of the 
axillary artery; the best results were obtained in the old luxations 
of not more than two months' standing, for which 50 to 75 per cent, 
function was obtained. He approached the joint through an incision 
between the deltoid and pectoralis major. The pectoralis minor is 
retracted upward and the major down. The spinati, teres minor, 
and coracobrachialis are now in front of the head. They are retracted, 
and the subscapularis is brought into view by the rotating of the 
arm outward. Its tendon is severed and the dislocation is then reduced 
by Kocher's method, after which the subscapularis is sutured to its 
insertion. 

A large proportion of other operators, especially American surgeons, 
believe that the fibrous restrictions from torn capsule and periosteum 
about the displaced head are the cause of irreducibility in these dis- 
locations, and most of them favor open operation by an anterior 
approach. Jonas^ reported 11 cases, the greater number of them 
approached by incision through the deltoid, 1 by the axillary route. 
Nine cases were operated on, 7 w^ere reduced, and 2 w^ere treated by 
resection. He believes that the deltoid and supraspinatus offer great 
resistance to reduction. In 1 case he found the glenoid edge so 
flattened that the bone gradually slipped out of place again. In all 
but 2 of his cases the contour of the head was normal, in these 2 
there was flattening or a groove in the posterior surface. Three had 
tearing off of the greater tuberosity. The final outcome of all cases 
was improvement, although none were restored to full use, a condition 
which it would be almost impossible to hope for. Schultz and Kuttner 
found after arthrotomy in recent dislocations that only 12 per cent, to 
15 per cent, gave normal function. Pain and circulatory disturbances, 
however, always disappeared. Some atrophy of the deltoid persisted. 
Other operative cases have been reported by PooP and Jopson^ with 
fair results. Jopson could not make reduction until the anterior 
and outer fibers of the capsule were incised. Pool advises excising 
the head for greater freedom of motion, and replacement in normal 
position for strength, and he suggests preservation of the anterior 
capsule as much as possible. Hotchkins reported^ 8 operated cases, 
5 reduced after arthrotomy, and 3 resected heads. 

Andrews, in 1905, strongly advocated the anterior approach by resec- 
tion of the pectoralis major muscle close to its insertion after an 
experience based on radical removal of the breast and a review of the 

» Ergebnisse der Chir. unci Orthop., iii. 2 Ann. of Surg., li, 890. 

' Ibid., Iv, 620. * Ibid., Iviii, .542. 

' Ibid., April, 1904. 



440 DISLOCATIONS OF THE SHOULDER 



technic of Rearink, Oilier, Korte, Dollinger, Keetley, and others 
previously mentioned. This approach avoids danger to the axillary 
vessels and nerves, because they are retracted out of the way after 
the muscle is severed. The capsule is then cut or nicked with the 
help of rotatory arm movements, and, after the restrictions are all 
cut through by a pull of a steel hook passed around the neck, the bone 
is slipped back into the socket. The pectoralis muscle is then sutured 
together by mattress stitches, and the arm is put in an immobilizing 
dressing for two weeks. Cautious use is then commenced, and results 
are satisfactory. I have reduced three old shoulder dislocations by 
this method and like the exposure, the opportunity to free adherent 
vascular structures, and the satisfaction of seeing the head go back 
into the glenoid. In 1 case I had to incise the capsule and fibrous 
mass for over two-thirds of its circumference. Function of 30 per 
cent, to 45 per cent, resulted, and these must be considered fair results 
as the cases were all of some months' standing. 



1 



1 



CHAPTER XVII 



FRACTURE OF THE [FOREARM BOXES. 

(1) At the proximal end: the olecranon; coronoid process of the 
ulna; head and neck of the radius; (2) The shaft of one or both 
bones. (3) At the distal end: styloid process of the ulna alone; Colles's 
fracture of the radius and both bones near the wrist. 

1. Fractures of the Olecranon Process. — ^The ulna develops from 
three ossification centres, as represented in Fig. 243, and injuries 
of the olecranon rarely occur through the epiphyseal line. 

Olecranon 

__ Joins body at 
sixteenth year 



Appears at. 
tenth year 



In the series of 10,702 fractures 

examined by me at the Cook County 

Hospital the olecranon was concerned 

in 91 instances, or 0.85 per cent. In 

1914 there were 16 instances, 3 of 

which were complicated by condylar 

fracture of the humerus. The plane 

of fracture may run transversely or 

obliquely across the olecranon at any 

point from the tip to an inch distal 

to the coronoid process, passing into 

the elbow-joint (Figs. 244-247). This 

plane is generally straight, but it 

may be irregular. There may be 

little or no separation, or the frag- 
ments may be widely displaced and 

the proximal fragment pulled up by 

the contraction of the triceps muscle. 

In some instances there are two or 

more fragments, and the fracture is 

comminuted. If one bears in mind 

the manner of bone separation under 

stress of ligamentous pull, it is evident 

that a large percentage of olecranon 

fractures are caused not by direct 

violence but by a sudden increase in tension of the pull of the triceps 

tendon. Possibly seven out of ten fractures of this process are of the 

oblique type with little separation of fragments, the plane running into 

the joint, and exhibit over the olecranon area of skin no evidence of 

direct trauma. The other 30 per cent, of cases are those in which 

the fracture is complete; that is, the plane is more directly transverse, 

and the separation of fragments is distinct. Included in this class 



Appears at 
fourth year 



Joins body at 
twentieth year 



Inferior extremity 

Fig. 243. — Plan of ossification of the 
ulna. From three centres. (Gray.) 



442 



FRACTURE OF THE FOREARM BONES 



and representing some 10 per cent, of the whole, are the comminuted 
cases caused by a combination of muscular pull and direct trauma. 





Fig. 244. — Fracture of the olecranon 
in a child. The upper fragment re- 
tracted by the triceps tendon. 



Fig. 245. — Fracture through the epi- 
physeal line. No separation. 





Fig. 246, — Transverse fracture of the 
olecranon with fragment retraction. 



Fig. 247. — Oblique fracture of the olecranon. 
The elbow-joint is always opened. 



When a person falls on the supinated forearm, his muscles instinc- 
tively tighten to break the force, and as he receives the impact there 



FRACTURES OF THE OLECRANON PROCESS 



443 



is a sudden great increase of stress in the region of the triceps insertion 
on the olecranon. The crushing weight of the fall causes the ulna to 
be pulled over the end of the humerus as a fulcrum with the triceps 
rigid, and this causes the bone to give. The line is transverse or 
oblique, depending on the sharpness with which the weight is suddenly 
transmitted, the sharper the increased tension, other factors being 
equal, the more transverse the fracture line. The amount of separation 
following depends on two conditions, first the amount of tear in the 
capsular ligament of the elbow-joint, including the periosteal rupture, 




Fig. 248. — Fracture of the ole- 
cranon and coronoid process and 
inward dislocation of the elbow. 
Note the radial head approxima- 
ting the internal epicondyle, and 
the olecranon lying directly inside 
the lower end of the humerus. 



Fig. 249. — Fracture of the olecranon and dis- 
location of the radius and ulna forward. The 
olecranon fragment has remained in its relation 
to the trochlea. 



and secondly, the reception of some direct trauma over the olecranon 
area when the injured elbow comes in contact with the ground. These 
fractures can be compared with patellar fractures in many ways. The 
plane of fracture starts most frequently at the narrow portion of the 
process, its weakest part, and differs from experimentally produced 
separations following blows by a hammer when the cadaver muscles 
are lax. These artificial fractures are always comminuted into several 
fragments, and there is no oblique plane as there is in all fractures 
arising from torsional violence. 
Muscular action by contraction of the triceps has caused this frac- 



444 FRACTURE OF THE FOREARM BONES 

tuiv in a j)ers()ii overexerting in throwing a ball or other object. 
Hyperextension of the forearm may also cause fracture of the olecranon 
because of the fact that the tip of the process impinges against the 
olecranon fossa of the humerus. Capsular stretching or tear permits 
the ulna to extend beyond its usual range, and the tip is split off from 
within outward. Fracture of a condyle or dislocation forward of the 
head of the radius may accompany this type (Figs. 248 and 249). 

Symptoms and Signs. — Pain in the elbow, swelling and tenderness 
on pressure over the olecranon, are the common symptoms. Volun- 
tary extension may be limited, especially if there is separation of 
fragments, and the patient prefers not to make this motion on account 
of pain, holding the forearm comfortably about two-thirds extended. 
In recent injury when the plane of separation is complete and the 
upper fragment is separated, crepitus is easily demonstrated. By 
flexing the forearm the attendant can see or feel that the upper frag- 
ment does not move with the forearm, and in complete fracture he 
may find a definite sulcus between the fragments into which a finger 
can be laid. 

Much of the swelling is in the olecranon area, the elbow-joint as a 
whole showing little reaction. After the lapse of two or three days 
the bursa over the olecranon process may become the seat of swelling, 
and the skin around becomes edematous and painful, so that it is 
difficult to diagnose fracture or a traumatic bursitis. The use of the 
Roentgen rays shows that a large percentage of olecranon injuries are 
really fractures that have little separation, so that in the pre-Roentgen 
era there was doubtless a large proportion of cracks through this 
process which were not recognized as fracture. The heavy capsular 
and elbow ligaments blend with the periosteal covering of this process 
and have more to do with the amount of the separation than the 
pull of the triceps tendon. The bone may be cracked and slightly 
separated across its continuity, but if there is no accompanying liga- 
mentous or capsular tear, no separation will follow when the forearm 
is brought into flexion. The process may be badly comminuted and 
yet not separated, if this ligamentous envelope retains its integrity. 
The triceps does cause separation, if this tear permits retraction of 
fragments, and in many cases this action of the muscle is manifested 
at once. In old cases with separation, the proximal fragment tends 
to be pulled higher up, as this strong unopposed muscle contracts, 
but it cannot draw the fragment above the olecranon fossa of the 
humerus, unless the capsular and periosteal attachments are loosened. 
Consequently in most cases seen early, before there is pronounced 
swelling or infiltration, full extension of the forearm with slight press- 
ure down on the upper fragment serves to bring the two into contact, 
and crepitus is obtained. If the upper fragment has been broken off 
obliquely, ending in a sharp point and much displacement, this pro- 
jection may puncture the skin or threaten pressure necrosis, if the 
olecranon area has been damaged by trauma. Dislocation forward 
of the ulnar shaft accompanies this type. In fresh injuries there is 



FRACTURES OF THE OLECRANON PROCESS 445 

sufficient ground for diagnosis of fracture if the power of active exten- 
sion is diminished and there is present swelHng and a persistent point 
of tenderness, when the process is examined by digital or pencil-end 
pressure. In old cases the presence of bursitis must be excluded, and 
a Roentgen picture should be made if possible. 

The character of the repair of the fracture does not need the dis- 
cussion it was formerly entitled to, as we now have in the Roentgen 
rays a means of deciding whether, after due time, a union is bony or 
fibrous. Furthermore, the extent of restoration of function in the 
forearm does not depend so much on the question of bony or fibrous 
union between the fragments as it does on the presence of intra- 
articular projecting callus, lacerations of the periosteum with the 
formation of bone deposits into the articular capsule, and a thickening 
and shrinking of the capsular structure which interfere with joint 
motion. Practically all olecranon fractures with little separation or 
with fragments brought into reasonable apposition by treatment 
result in bony union. This fact I have verified by skiagrams taken 
in the course of weeks or months after injury. If there is a wide 
separation of fragments and the fracture is not treated by open opera- 
tion, fibrous union does result in some cases, and in nearly all of these 
the functional result is good, if the arm has been treated in extension. 
In a small proportion complete extension of the forearm is lost, but 
as the movement of flexion is one of greater importance in function, 
this partial disability of extension is never noticed. Bony union does 
not depend so much on the line of fracture or the number and shape 
of the fragments as it does on proper apposition of them in the treat- 
ment. Rarely the periosteum of the tip of the process becomes 
lacerated, and some callus is thrown out here beneath and possibly 
into the triceps tendon, which may become adherent to the olecranon 
fossa and preclude use of the joint. If a strong fibrous union is 
obtained, this may stretch a little after use, but the triceps take on a 
little shortening by contraction of the muscle length, and function is 
satisfactory. 

Jones^ states that the cases which he has treated by wiring do not- 
surpass those treated non-operatively, and that although operation 
leads to a larger percentage of good anatomical results the difi'erence 
in functional results of the two methods of treatment is small. The 
operative results give 77 per cent, good functional results compared 
with 75 per cent, by non-operative treatment. 

Non-union rarely occurs and arises from improper immobilization 
and eft'ort to approximate the fragments, or the falling between of a 
piece of periosteum or capsular ligament which had been stripped oft' 
the bone. ^Modern treatment in cases of complete separation eradi- 
cates this result. We should expect a happy result from open treat- 
ment. Fibrous union of the fragments may be present, but if the 
capsular and ligamentous structures have healed firmly, and too early 

1 British Med. Jour.. December 7. 1912. 



44G FRACTURE OF THE FOREARM BONES 

use has not resulted in stretching of the scar in these structures, the 
function may be very good. That non-union is not feared, partly on 
account of lack of separation and partly of good reduction as evidenced 
by the roentgenogram, is demonstrated by the sixteen fractures of 
this process treated at the Cook County Hospital in 1914. But three 
of these were subjected to open operation, and yet the result in every 
case was good to excellent. 

Stiffness in the joint, incomplete extension or flexion, and pain 
arise from the conditions mentioned above following intra- and peri- 
articular damage of callus or thickening and are not frequent. 

Treatment. — It can be stated that treatment depends largely on 
the separation of the fragments, because this separation is an indica- 
tion of the accompanying pathology in the other joint structures. 
Simple transverse or oblique fracture near the end of the process, 
the fragments of which are not separated and do not tend to become 
so when the forearm is flexed, can be supported in a sling with the 
arm nearly at a right angle. If this position tends to cause fragment 
distraction, the forearm is maintained in a position of extension which 
allows approximation and is held there by a light moulded plaster-of- 
Pairs splint applied on either surface of the limb. If the local reaction 
is severe and the swelling and joint distention are the most marked 
symptoms, the arm is placed on a pillow in a comfortable position 
and an ice-bag is applied for a few days until the swelling subsides. 
The joint may be drained by the trephining of the olecranon accord- 
ing to Doberaner's suggestion in suppurating elbows,^ In a few cases 
of little separation the fragments cannot be approximated unless 
complete extension of the forearm is obtained. 

If the process is comminuted or the oblique upper fragment threatens 
skin puncture, the covering of the elbow must be kept aseptic by an 
alcohol wash or half-strength tincture of iodine and dry sterile dressings. 
Then complete extension is obtained by an anterior moulded plaster 
splint, and the position of fragments is checked by a roentgenogram. 
The strapping of the upper fragment as a means of pulling it down or 
preventing tipping can be accomplished by the use of U-shaped, 
narrow strips of adhesive tape or of long pieces which cross just above 
the olecranon tip and run well down on to the forearm, or of a small 
pad pressing down on the top of the olecranon and strapped firmly in 
position. 

Hooks, locked into the upper fragment or caught in the triceps 
tendon and extended to attachment in a permanent plaster dressing 
or cuff below, are not used in modern practice. These are much like 
Malgaigne's hooks in treatment of the patella. I have never seen them 
used, and while they are undoubtedly of value where open treatment 
could not be obtained, they are practically never employed. 

Open treatment is reserved for those cases of wide separation, com- 
minution, tilting, or presence of a fragment loose in the joint which 

1 Miirich. med. Wchnschr., Ixii, No. 14. 



FRACTURES OF THE OLECRAXOX PROCESS 



44: 



cannot be fully and satisfactorily reduced and held by splinting and 
strapping. One very good method encircles all fragments with a 
silver wire which passes through the triceps tendon above and through 
a hole drilled in the transverse axis of ulnar shaft below. This when 
tightened, brings all fragments and the capsular structures into good 
position and the operation can be performed through a two-inch 
incision on the point of the elbow. The forearm is put up in three- 
quarters extension with an anterior moulded plaster splint. Silk or 
linen may be used also for this suture, and it is better applied through 
the triceps tendon than through a hole bored in the uppper fragment, 
as this may be split in the process and by the tendinous route but one 
hole has to be made in the bone. Small loops of wire in the long 
axis of the ulna do not hold well, are difficult to introduce, and lie 
very superficially. 




Fig. 250. — Anteroposterior 
view of comminuted olecra- 
non ^\-ith separation of frag- 
ments 



Fig. 251. — Repair of pre- Fig. 252. — Anteropos- 
ceding by ivory peg — lateral terior view of repair by 
view. ivory peg. 



In comminuted fractures I have sometimes used ivory pegs or metal 
nails, preferring the former (see Figs. 250, 251, and 252). The peg is 
introduced through a small incision over the upper fragment, and, 
after a drill hole has prepared the way, driven down into the ulnar 
shaft. The arm must be held in extension during this operation, and 
care must be taken to avoid the joint surface. The arm is dressed in 
extension. On the whole the encircling wire suture is the best treat- 
ment if operation is indicated, as it tucks all fragments snugly together 
and also includes the other structures. Usually it holds very firmly, 
and passive motion can be started on the eighth or ninth day in the 
• lirection of flexion. 



448 FRACTURE OF THE FOREARM BONES 

Course. — In simple treatment after the fourteenth day the spHnt 
is removed and a small amount of passive motion is given the elbow. 
This must not produce pain nor rupture the delicate adhesions between 
fragments. P^ach day this is repeated, and in the third week massage 
is begun. Union should be complete by the end of the fifth week, and 
active use can then be inaugurated. 

After open operation the course is about the same. If the skin is 
closed with clips, these are all taken out by the end of the first week. 
After the second week motion and massage are given as above, and 
if wide separation was treated, the splint should be left on five or six 
weeks, when bony or firm fibrous union will be present. Attainment 
of use of the arm requires some additional three weeks. 

Old cases of non-union, or of fibrous union with impaired extension 
power or interference with joint movement, are treated by more 
elaborate operation. If it is a case of simple stretched fibrous union 
with normal joint structures, this band is dissected out, the ends of 
the fragments freshened by a very sharp chisel, and the fragments 
wired together. If interference with joint function is found to be 
caused by excessive callus, thickened capsular structures, or the 
tilting of a fragment into the joint surface, these must be dealt with 
as found, and the possibility of capsulotomy or the insertion of fat 
and fascia, as in arthroplasty, must be considered after bony excess 
is chiseled away, that new adhesions may not form. 

Epiphyseal Separation. — ^The epiphysis of the olecranon shows begin- 
ning calcification in roentgenograms of eight-year-old children; by 
the tenth year there is a well-marked centre occupying one-third of 
the process, and union takes place with the rest of the olecranon in 
the seventeenth year (Poland and Gray). Of the 16 cases of olecranon 
fracture mentioned above, 4 were in patients in the eighth or ninth 
year, 1 was in a fourteen-year-old boy; and 2 of these were distinct 
epiphyseal separations. This has been considered a rare epiphyseal 
injury and is caused by stress on the triceps insertion as in olecranon 
fractures, or by a sharp blow of direct violence, as in a fall with the 
forearm in flexion. In childhood the olecranon is proportionately 
smaller in size and its projection less prominent than in adults, so 
that when the forearm is flexed to a right angle, the posterior edge of 
the epiphysis in children up to fourteen years of age, lies anterior to 
the plane of the humeral shaft and its epicondyles. Consequently, 
when a child less than fourteen or fifteen years old falls on the elbow, 
he is more apt to receive a fracture of the condyles than of the ole- 
cranon, as the former processes are exposed to the violence. Hyper-- 
extension with resulting dislocation of the head of the radius may 
also cause this epiphysis to separate. 

A case in a nine-year-old boy has been reported by Skillern,^ and in 
Holmes's System of Surgery,^ out of a total of 2705 fractures 76 were 
of the olecranon, 10 of those occurring before the tenth year of age. 

1 Ann. of Surg., liii, 873. 2 1881, i, 845. 



FRACTURE OF THE COROXOID PROCESS 



449 



If the diastasis between fragments is great and there is reason to 
believe that periosteal or other tissues have fallen between the frag- 
ments, open operation should be the treatment, as a means not only 
of promoting union but of preserving the growing function. In minor 
separations, treatment in a moulded plaster splint in three-quarters 
extension for two weeks is sufficient. 

Fracture of the Coronoid Process. — This fracture is also considered 
rare, and there are few references to it in the literature. Robert 
Jones^ says he has encountered several instances 
of it and believes that it is much more frequent 
than reports show. He had one case followed 
by a traumatic myositis ossificans and has knowl- 
edge of several cases followed by a fresh accu- 
mulation of bone after removal by operation. 
In the last year I have seen two cases of this 
injury : one a linear crack from the proximal edge 
of the process running down into the shaft of the 
bone, and the other a transverse fracture with 
a fair-sized fragment completely displaced for- 
ward. Neither of these cases was accompanied 
by dislocation at the elbow, and in cases of old 
posterior elbow dislocations which I have operated 
on I have never found a separate fragment, or 
evidence of fracture of the coronoid, although I 
have looked for them. ^lany authors assert that 
the dislocation is necessary to cause this frac- 
tiu*e (Fig. 253). Indirect violence transmitted 
from the forearm is the usual cause, although 
direct violence might act. 

Stimson- quotes the results of Lotzbeck, who 
obtained fracture of the coronoid in five out of 
ten attempts by striking the palm of the hand 
when the elbow was fixed in a slightly flexed 
position. A sudden sharp contraction of the 
brachialis anticus muscle, which is attached on 
the anterior surface near the base of this pro- 
cess, may cause a splitting oft' of the bone with 
an oblique plane of separation. In these cases, if the separation is 
complete, the distal point of the fragment is tilted up, whereas in 
fracture caused by indirect or direct violence and with a more trans- 
verse separation, the fragment is held down in place beneath the 
insertion of this muscle, which remains intact. To permit displace- 
ment, tearing of the joint capsule as well as the periosteum must 
take place, and it is these structures which retain connection with the 
fragment and supply it with nutrition and promote union. 




Fig. 253. — Fracture of 
the coronoid process. 
Note the tendency of 
fragments to wander into 
the joint. 



29 



' Proc. Roy. Soc. Med., England, December, 1910. 
' Fractures and Dislocations, 1913, p. 245. 



450 FRACTURE OF THE FOREARM BONES 

Symptoms and Diagnosis. — In linear or sprain fracture with no 
separation there is some swelling over the anterior aspect of the elbow 
and pain on pressure over the process. Rapid flexion of the arm may 
be painful. The Roentgen examination gives the only sure diagnosis. 
If a fragment has been separated and is displaced forward, it may be 
felt as a freely movable mass beneath the brachialis tendon, or crepitus 
may be obtained by the surgeon rubbing the coronoid process back 
and forth with the forearm in partial flexion. It may be possible to 
push the loose fragment into position, but recurrence of the dis- 
placement usually follows at once, if the pressure is removed. 

Treatment. — Treatment consists in the fixing of the arm in a moulded 
plaster splint in a position of flexion, about 60 degrees for cases of 
moderate displacement, or in full flexion if the fragment tends to be 
dislocated completely forward. If the process is merely cracked or 
there is no separation, fixation in a sling with the forearm at a right 
angle is maintained until soreness has left the joint. Active use is 
cautiously begun. In old cases if the fragment interferes with joint 
movement by mechanical pressure it should be excised. 

Fractures of the Head and Neck of the Radius. — ^These fractures have 
been rare for the most part on account of the difficulty of diagnosis 
before the advent of the Roentgen rays, only 21 cases being reported 
up to 1880, although the first case was known in 1834. Most of these 
21 cases were the result of postmortem examination. In 1905 Thomas^ 
collected 45 cases in the literature. Since that time many other 
reports have come, the largest being that of Stocklin, who cited 26 
cases. In a large city hospital where all suspected fractures or obscure 
injuries are subjected to Roentgen examination, these fractures are 
found every few months. In 1914 at the Cook County Hospital there 
were 2 cases of fracture of the head and 1 of the neck, also a buckling 
fracture high up near the neck. 

The radial head rotates through an are of nearly 180 degrees held 
by a sling formed by the lesser sigmoid cavity of the ulna and the 
orbicular ligament. Injuries of the head and neck consequently often 
lead to interference with rotation of the forearm, especially supination 
or flexion and extension of the elbow. The line of fracture is usually 
vertical and occurs within the orbicular ligament, or it may be trans- 
verse, complete or incomplete, so that a fragment is split off freely. 
Children are prone to the incomplete transverse type and the sub- 
periosteal fracture with buckling of the neck. Epiphyseal separation 
is also found, while in adults the longitudinal, complete or incomplete 
variety is the usual finding. If a fragment is split off by the longitud- 
inal cracks, it usually retains its connection to the shaft by periosteum 
or ligament shreds. 

Causes. — Blows of direct violence, or a fall on the elbow which 
results in direct violence to the head of the bone is the most frequent 
cause, especially in fractures of the neck or transverse fractures of 

1 Univ. of Penn. Med. Bull., xviii. 



FRACTURES OF THE HEAD AXD NECK OF RADIUS 



451 



children. Small fragments may be chipped off the head from direct 
violence in dislocation of the radius either by impingement against 
the capitellum of the humerus or possibly by the mechanism of sprain 
fracture, a pulling out of the bony surface by ligamentous attach- 
ment (Figs. 254 and 255). Stimson believes that longitudinal splitting 
of the head and separation of fragments is caused by ^•iolent wrench- 
ing of the forearm and cites 5 cases seen by him (Figs. 256 and 257). 
Falls on the palm of the hand with resulting indirect violence on the 
radial head are disputed mechanisms, and in the subperiosteal or 
buckling type in children these are probably the cause. 




Fig. 2.54. — Longitu- 
dinal fracture of the 
radial head, a condition 
easily overooked. This 
is a true joint fracture. 




Fig. 255. 



-Lateral view of a similar fracture shown in 
the preceding picture. 



In fissures or longitudinal cracks of the head and neck there is 
no displacement of fragments, and if the line is strictly within the 
orbital ligament there is no crepitus. On attempts at supination 
of the forearm, however, there is pain and muscular spasm, so that 
this motion is greatly limited. There is also distinct pain on direct 
jjressure over the radial head, aggravated when the hand is grasped 
by the examiner and the forearm rotated. If transverse fracture 
exists beloir the orbicular ligament, there is more separation of frag- 
ments, the head may be displaced outward and forward, or a piece 



452 



FRACTURE OF THE FOREARM BONES 




Fig. 256. — Small comminuted frag- Fig. 257. — Postoperative picture of the 

ments clipped off the radial head preceding showing removal of the head of the 
by striking the capitellum. radius. There was fair ultimate function. 




Fig. 258.— Incontpjlelc fracture of the radial head caused by muscular action and 

indirect violence. 



FRACTURES OF THE HEAD AND NECK OF THE RADIUS 453 

broken out may come to lie at any point of the joint anteriorly or 
laterally, especially if elbow dislocation has been a complication. In 




Fig. 259. — Separation of a fragment from the head caused by muscular action and 

indirect violence. 




Fig. 200. — Subluxation of the ulna at the elbow with impacted fracture of the head of 

the radius. 



this type crepitus is usually present in addition to the restricted 
supination and pain (Figs. 258, 259, and 260). 



454 FRACTURE OF THE FOREARM BONES 

Broken-off heads have united, always with displacement and loss 
of function. Sometimes the bone ends become smoothed over, and 
non-union results with a varying degree of functional interference. 
The radial nerve may become involved in the callus or be injured 
primarily. (See Dislocations of Head of Radius.) 

Diagnosis. — In the fissure type of fracture of the head without dis- 
placement diagnosis is made on the limited rotation of the forearm, 
especially the painful supination, the evidence of blood extravasation 
about the head, and a point of great tenderness when pressure is made 
by an examining finger. Transverse fracture of the head with dis- 
placement of a fragment or fracture through the neck which displaces 
the whole head have in addition to the above findings a crepitus 
when the forearm is rotated, or the loose fragment is distinctly palpable 
in the joint structures near the olecranon. Jarring the forearm in 
its long axis also gives pain at the site of injury, and the type of 
fracture is settled by the Roentgen rays. 

Treatment.— Treatment should aim to preserve function. If the* 
fracture is seen early and there is a loose fragment at any part of the 
joint, it should be removed at once by operation. Linear cracks with 
no separation demand but little treatment; immobilization should 
be short and active use should be made of the joint after ten days 
to avoid shrinking of the capsule and restricted motion. In children 
the results are frequently very happy, even if the Roentgen picture 
promises poorly, but some restriction of forearm movement always 
follows. Stoecklin,^ out of 26 cases performed operation in 12, leaving 
for conservative treatment those cases which were the inilder, and the 
results were good for all except 1. Of the operated cases, which 
were severe, the results were very bad in 3 instances, with great 
restriction of supination. A series of 19 cases was reported by Hitzrot.^ 
The best results were obtained in the 4 cases in which the loose frag- 
ments or whole head were removed; the greater the amount of bone 
removed, the better the result. Hammond^ agrees with this. Of the 
15 cases treated conservatively, nearly all lost at least one-half of 
their forearm rotation. Radical and early operative removal of the 
loose head is the most satisfactory treatment. 

Fractures of the Shaft and Lower Ends. — Colles's Fracture. — ^In the 
review of 10,702 fractures at the Cook County Hospital the radius 
was found to be involved 826 times, or 7.7 per cent., and the ulna 414 
times, or 3.8 per cent. The lesions were distributed as follows: 

The radius alone, in its shaft or head 158 times 

Colles's fracture 533 " 

Fractures of both bones of forearm 135 " 

The ulna 414 " 

The shaft of the bone .... 188 " 

Olecranon fractures 91 

Fractures of both bones of the forearm . . .... 135 " 

' Loc. cit. 

2 Ann. of Surg., March, 1912. 

3 Ibid., lii, 207. 



FRACTURES OF THE SHAFT AND LOWER ENDS 455 

During 1914 many patients, especially those with Colles's fracture, 
were treated without being entered on the permanent records. The 
fractures were reduced in the wards, the position determined by 
roentgenogram, and the individual treated as an out-patient. In 
that year there are records of 86 cases of fracture of the radius dis- 
tributed as follows: 

The head 2 cases 

The neck 1 " 

Buckling fracture near head 1 " 

Colles's fracture 54 " 

All others, mostly middle and upper third 28 " 

Fracture of the ulnar styloid accompanied 15 of the Colles's frac- 
tures, and the carpal scaphoid was fractured in connection with 1. 
There were 2 instances. of double Colles. 

The ulna was broken alone or as indicated, 31 times, the site of 
fracture being distributed as follows: 

Olecranon 15 cases 

Complicated by fracture of the humeral condyle .... 2 times 

Onar styloid alone 2 cases 

Coronoid process . . 2 " 

Upper and middle third 12 " 

Fractures involving both bones of the forearm were 51 in number, 
5 of which were open. These were: 

Radial head and coronoid of ulna 1 case 

Green stick 1 " 

Lower epiphyseal separation 1 " 

Double fracture both forearm bones M " 

Both bone fracture of other levels 47 " 

Most fractures of the shaft of bones involve the middle or lower 
thirds, and the ulna is usually broken lower down than the radius. 
When fracture force affects the forearm low down, the radius alone 
is usually broken (Figs. 261 and 262). 

Causes. — Direct violence by a sharp blow across the outstretched 
forearm, twisting violence from a catching of the forearm in a wheel 
or machinery, or forcible compression of the forearm across an edge 
or solid mass causes the compression fractures. Indirect violence 
from falls on the hand or from muscular action and body weight cause 
the torsion fractures. These may be combined as in the leg, so that 
the torsion and compression mechanism act together. A third class 
of fracture, many of which were formerly called green-stick fracture, 
are now known to be buckling or compression fractures in the longitu- 
dinal axis of bones (Figs. 263-267). These occur in youths or adoles- 
cents and arise from a telescoping action of the cortex which gives way 
and bulges out laterally. (See figure of buckling fracture of humerus, 
anrl also figure of fracture of radius.) Rarely this involves the 
whole circumference of the cortex, and the slight shortening is uniform. 



456 



FRACTURE OF THE FOREARM BONES 



so that there is no axial deviation of the bone ; in many cases involving 
the forearm bones this buckling involves but one side of the shaft 
and there is an axial deviation. 

Skillern^ has attempted to isolate a group of forearm fractures in 
children which are characterized by complete fracture of the lower 
third of the radius with dorsal and lateral displacement of the lower 





Fig. 261. — Fracture of both 
bones at about the middle caused 
by direct violence. The plane of 
fracture in the ulna is lower than 
in the radius. 



Fig. 262. — A typical fracture of both forearm 
bones in a child, trainsverse in type, little separ- 
ation, ulna fracture lower than the radial. Un- 
toward manipulation of this fracture might pro- 
duce a serious deformity. 



fragment and an incomplete green-stick fracture of the inner side of 
the ulna at a higher level. These are supposed to constitute 13 per 
cent, of all forearm fractures. They are the result of the compression 
and torsion mechanism and are really quite typical because the child 
falls on the hand — the radius is broken by indirect compression, and 
the ulna takes up the torsional stress at a higher level when the radial 



> Ann. of Surg,, Ixi, No. 2. 



FRACTURES OF THE SHAFT AND LOWER ENDS 



457 



support is lost. Fig. 268 represents a fracture of this character in 
which the radial epiphysis has been displaced and there is a buckling 
fracture of the inner edge of the ulna. I believe that these fractures 
are relatively rare. 

Pathology. — The displacement of fragments in fracture of both 
bones may assume any of the usual varieties. In simple compression 
fracture without separation (see Fig. 262) the two bones are bent 







263 Fig. 264 Fig. 265 

263. — A more delicate type of fracture 



Fig. 266 Fig. 267 

in a child. In the ulna there is a true 



Fig 

Fig 
green-stick fracture. 

Fig. 264. — Complete fracture of the shafts of both bone with angular deformity. 

Fig. 26.5. — A frequently found type of fracture, both forearm bones. 

Fig. 266. — A lateral \-iew, the ulna broken higher up. Axial rotation and overlapping. 

Fig. 267. — Angular deformity and slight rotation. The ulna is broken lower than 
the radius. Verj- little torsion in the mechanism. 



at an angle in accordance with the direction of the causative trauma. 
If there is complete loss of continuity, a triangular piece may be 
split off, as in other bones, and there is angularity and overriding, 
giving shortening as great as two and a half inches in the forearm 
(Fig. 269). Torsion results in spiral fractures which tend to override. 
On account of the surrounding muscles and the interosseous ligament, 
displacements are both restricted and complicated. An adult man 
with a heavy muscular forearm always presents marked deformity 



458 



FRACTURE OF THE FOREARM BONES 



and overriding in fracture of both bones. The radius may present 
rotatory displacement caused by the upper fragments being pulled 
into supination by the biceps muscle and the lower fragments being 
pulled into relative pronation by the pronator teres muscle when 
the line of break lies above its insertion. (See Fracture of Radial 
Shaft.) Healing in this position would greatly restrict rotation of the 
forearm. Transverse fracture may give much angular deformity, and 
is often accompanied by overriding. If the four bone ends are directed 





Fig. 268. — Displacement of the lower 
epiphysis of the radius with linear 
compression fracture of the upper part 
of the ulna. 



Fig. 269. — Overriding fracture of both 
bones in an adult forearm. Note the 
rotation. 



in the same lateral inclination there is also marked angular deformity, 
and the most undesirable displacement of all is lateral angulation 
of the four bone ends toward each other. If this position remains 
uncorrected, there is a bony mass in the forearm when all are grown 
together, and rotation is coinpletely lost. Nerve injury is rare. 

Symptoms and Diagnosis. — There is always great loss of function, 
pain, deformity, a point of abnormal movement, and frequently 
crepitus. Usually the fracture is apparent at a glance, although it 
may not be so easy to decide whether both bones are completely 



FRACTURES OF THE SHAFT AND LOWER ENDS 459 

broken or not. The examiner should clasp tl^e injured hand in his 
corresponding hand and by gentle rotation, the thumb of his other 
hand palpating along the radial side of the patient's forearm, dis- 
cover the condition of the radius and the point of the break in it. 
The ulna, which does not move in rotation and which lies superficially, 
can next be palpated in its whole length and its condition determined. 

In children, or in non-muscular forearms the diagnosis can readily 
be made, and the course is usually a progressive one to a prompt 
union, in four or five weeks. In muscular adults diagnosis and reduc- 
tion are more difficult, and complications are frequent. Overriding 
with angulation of the bone ends, comminution, or great swelling and 
displacement lead to trouble. Bony union with deformity may occur, 
causing lack of rotation or interference with muscular action in the 
hand, the tendons of the forearm having become adherent to the 
callus. Great displacement results in non-union frequentl}', and 
there is a flail-like joint in the forearm which permits but a few degrees 
of motion and which weakens the power of the hand. Volkmann's 
ischemic contracture (see chapter on Pathology) or gangrene of the 
extremity is also not an unusual complication when treatment is not 
thoughtfully given and splints are put on too tight and not inspected 
frequently. If the cause of fracture is direct violence, the splints 
may cause a pressure necrosis at the point of application of the force, 
and I have seen several cases where an area two inches in diameter 
has sloughed out after two or three weeks from splint compression. 
This may leave the fracture site exposed and cause infection in the 
bone. The gangrene may be more serious and involve all the tissues 
distal to the fracture. In superficial ulceration and infection the 
tendon sheaths and muscles become involved, and contractions, with 
matted tissues adherent to each other and the bone, result with great 
loss of function. Secondary amputation may be demanded by a 
suppurative process which threatens life. 

Injury of these bones requires constant attention until the danger 
of compression from swelling within, or from the light bandage which 
takes on the contour of the forearm is past. The prognosis is also 
influenced by too early attempts at use or by the support of the 
forearm in a sling from the neck which permits gravity to drag the 
hand down and cause a recurrence of the deformity before the callus 
has become hardened. This recurrence of angularity or its persistence 
is the most diflScult problem in fracture of both forearm bones. Rota- 
tion is accomplished b}' movement of the radius alone, and in com- 
plete pronation the radius crosses over the ulna in an oblique line, 
while in complete supination the bones lie practically parallel and are 
separated by their greatest distance. When the fracture results in 
angulation of the bones in the middle third of their shaft, the inter- 
osseous membrane restricts the radius from describing a larger arc 
away from the ulna in supination, and this action is consequently 
greatly lessened. Ossification of the interosseous membrane and 
adherence of fascial and muscle sheaths also has an influence. 



460 



FRACTURE OF THE FOREARM BONES 



If the fracture of both bones is at the same level and from direct 
violence, all four bone ends may become ossified together to the 
detriment of forearm rotation and hand function. It is not necessary 




Fig. 270. — Lateral view of a similar transverse fracture of both bones in a young adult 
after reduction. An excellent result. 




Fig. 271. — First-class non-operative reduction of fracture of forearm bones. 



for the fragments of the two bones to be in contact for this unfortunate 
result to come about, as the periosteum on the inner surfaces may be 
split, comminution may drive small fragments toward the opposite 
bone, or osteogenetic cells may wander out into the interosseous 
membrane from both sides and a firm union follow 
clear across the space between all fragments. 

Delayed union is usually the result of improper 
treatment, insufficient reduction, or too early 
attempts at use. 

Treatment. — The indication for treatment is the 
correction of overriding and shortening and 
angularity of the bones. When the forearm is 
flexed at a right angle, an assistant can make 
good counter-extension by holding the arm while 
the surgeon grasps the hand of the patient and 
makes extension. The thumb of the other hand 
grasps the flexor surface of the fractured forearm, 
while the fingers are used for pressure on the 
dorsum. Careful extension is made in the direction 
of the axis of the distal fragment, the thumb and 
fingers attempt to straighten out the angularity 
or correct the overriding, and while the pulling 
force is at its height the forearm is supinated to 
bring the bones into position of greatest separ- 
ation (Figs. 270, 271, and 272). Anterior or pos- 
terior angularity can often be nicely corrected by 
this manipulation, but if much overriding or comminution of the bones 
exist, it may be impossible to secure end-to-end reduction of the bone 
and the efl'orts made may cause greater displacement in an opposite 




Fig. 272. — Reduc- 
tion of forearm frac- 
ture in a child by 
manipulation. 



FRACTURES OF THE SHAFT AND LOWER ENDS 461 

direction if the force is rough, or may result in the four bone ends being 
angulated together. 

After the surgeon is satisfied with reduction, lie must accompHsh 
fixation in this position without disturbing the result obtained. The 
position of supination affords usually the best anatomical replacement, 
and while the position midway between pronation and supination with 
forearm at right angle to the arm is sufficient in those fractures with 
little displacement and easy reduction, it does not suffice in the more 
difficult cases. This midway position is the most natural and com- 
fortable one that the arm can assume for any period of time, and it 
does not become irksome. To obtain greater separation between the 
bones the position of supination is decidedly better. (See Fracture 
of Radius Shaft.) Wooden splints of width sufficient to overlap the 
full breadth of the forearm will hold position firmly. Both the splints 
and the arm must be well padded with cotton that pressure may be 
avoided, and the forearm must not be bound by a circular bandage 
next to the skin. Such a bandage causes constriction if swelling 
follows reduction by manipulation; it covers up the forearm and 
disguises the position of the bones and also tends to press the bones 
together, no matter how loosely it is applied. Wooden or other splints 
with a padded linear ridge to fit between the bones have no value. 
If two broad wooden splints are applied, the posterior comes to the 
wrist from the front of the elbow, while the splint on the flexor surface 
extends from elbow to the base of the fingers, and the whole is strapped 
together by adhesive tape and makes a box-like appearance. In spite 
of padding this splint gives pressure and causes much more atrophy 
and other changes in the forearm muscles than moulded plaster. A 
plaster splint moulded in two pieces, one on either side of the forearm 
extending up on to the arm above and fastened in the same manner 
with adhesive tape, is lighter and easier to carry. Any splint applied 
after reduction must be observed repeatedly and removed in a few 
days for investigation of the condition of the forearm. A Roentgen 
picture is very desirable in forearm fractures; if but a limited number 
can be taken, it is much better to wait until the displacement has 
been corrected and then make a checking picture. Reduction results 
which seem good clinically may be glaringly at fault under the 
Roentgen rays and the surgeon may be guided in further treatment 
or advice and prognosis by his checking picture. It is not infrequent 
to make a half-dozen attempts to reduce these fractures of both bones 
before a satisfactory position is obtained or operative treatment is 
decided upon. 

In fractures of the upper third the attendant may maintain reduc- 
tion by continuous traction, putting the patient to bed, supinating 
the arm, and putting on adhesive strips to pull the arm out at a right 
angle ivhilc in .siiyiiiatixm. A strap or band for ('ounter-extension must 
hoM the patient from giving toward the weight on the arm. 

Supination is also obtained in cases where reduction can be made 
and overriding does not tend to recur, by the attendant putting the 



462 



FRACTURE OF THE FOREARM BONES 



patient to bed, abducting the arm, turning the forearm over into a 
supine position, and letting it He there. This causes much confine- 
ment; the same position can be maintained by the moulded plaster. 
(See Fracture of the Radial Shaft Alone.) Circular casts should not 
be used on forearm fractures. 

After three weeks in splints, with frequent inspections as to press- 
ure, condition of the skin and position of fragments, massage should 
be started, removing the splint for a half-hour daily. It is a mistake 
in most cases to remove splints before five weeks. I have seen several 




Fig. 273. — An example of plating 
not to be copied. Bone ends are not 
approximated; screws are loose and 
not fully inserted; plates give no 
stability. 




Fig. 274. — An unwise use of heavy 
plates in the delicate forearm bones 
of a child. 



recurring deformities after this period when callus was apparently 
firm, brought on by too early attempts at use or the wearing of the 
arm in a sling which allowed the hand to hang unsupported. 

Certain cases of overriding or oblique and comminuted fractures 
resist all attempts at manipulative reduction. These fractures should 
be treated by open operation and simple reposition, without a short- 
ening of or interfering with the bones in any way, provided the ends 
can be made to remain in alignment by this means. Pieces of peri- 
osteum lying between fragments are removed. Sometimes a small 
loop of wire will hold a bad displacement. Lane plates have been 



FRACTURES OF THE SHAFT AND LOWER ENDS 



463 



implanted on the forearm bones with excellent reposition of fragments, 
but a very large percentage of these plates become infected or lead 
to trouble which causes their early removal, and a longer convales- 
cence follows than after other methods. I do not believe that plates 
have any place in forearm fractures (Figs. 273 and 274). 

The best method of operative fixation is by the intramedullary 
splint. Separate incision is made over each bone at the site of fracture, 
on the dorsum of the forearm. The breaks are exposed through as 
small an incision as possible with the least injury to muscles and other 
tissues. They are then turned out of the wound, and if the shaft 
is not split, the medullary cavity is very slightly scraped out and a 
delicate peg is inserted. If the bones are broken at different levels, 





Fig. 275. — Repair of fracture of forearm 
bones by an intramedullary splint in the 
radius. 



Fig. 276. — Lateral view of the 
preceding. 



it may be sufficient to peg one bone, usually the radius, get it into 
perfect alignment, and attempt to set the ulna by the dressing, or 
by an incision over it also, get approximation by wire or kangaroo 
tendon (see Figs. 275 and 276). 

If the bones are broken on the same level it is possible to insert 
an intramedullary peg into both bones simultaneously, having all 
four bone ends exposed and sticking out at the same time through 
two incisions (Fig. 277) . This I have done once but know of no other 
case on record (Fig. 278). The usual splints are used after operation, 
and the same precautions are taken as if no open surgery had been 
performed. 

Open fractures of both bones of the forearm are treated in accordance 
with the instructions in the chapter on Treatment. If it is possible 



4G4 



FRACTURE OF THE FOREARM BONES 



to maintain some extension on the forearm in the manner described 
above, it is wise to do so until the wounds are healed. Subsequent 
operations to correct deformities can be undertaken later with safety. 
Fracture of the Shaft of the Ulna. — This is caused by direct violence, 
as falls on the ulna, or to sharp blows received on the forearm when 
a person is warding off threatened injuries to the head. These frac- 
tures are seen as the result of clubbing by policemen or slugging by 
holdup men with shotted leather or pieces of wrapped lead pipe. 





Fig. 277. — Final result in a case 
where one bone was fixed with an 
intramedullary splint. Although the 
callus seems abundant, there was an 
excellent clinical and functional result. 



Fig. 278. — Simultaneous intramedul- 
lary pegging of both forearm bones. 
The peg in the ulna failed to hold because 
a small fragment of the shaft broke out as 
the reduction was made. Good result. 



Pathology. — The fracture is frequently open. The plane of fracture 
may be transverse, oblique, or comminuted, and there is not a great 
tendency to displacement, although the lower fragment is frequently 
drawn over toward the radius by the pronator quadratus muscle 
(Figs. 279, 280, 281, and 282). As this is a compression fracture, a 
small triangular piece may be broken out, or the fracture may be but 
a linear crack. 

Symptoms. — The principal symptom is loss of active forcible exten- 
sion of the forearm, if complete solution of continuity has occurred. 
In fracture of lesser degree or cracks there may be little interference 
with function, but use is painful, and there is pain on pressure over 



FRACTURE OF THE SHAFT OF THE ULNA 



405 



the injured joint. As the radius is not broken, it acts as a sphnt in 
the forearm and prevents shortening. By following the shaft of the 
ulna with the examining finger the surgeon finds the painful spot or 
a depression or angularity in the bone. Forcible manipulation may 





Fig. 279. — Oblique fracture of the 
shaft of the ulna. The lower fragment 
is drawn toward the radius and the point 
of the olecranon shows evidence of 
injury. 



Fig. 280. — Linear transverse fracture of 
the ulna alone in an adult arm, caused by 
direct violence. High up in the radius 
is an incomplete plane of fracture, green 
stick in character. 



eHcit crepitus, or a false point of movement can be demonstrated in 
the shaft. 

This fracture frequently accompanies dislocations of the head of 
the radius forward and is not recognized on account of the more 
30 



46G 



FRACTURE OF THE FOREARM BONES 



severe injury. Fisk^ records an unrecognized case which was followed 
by Volkmann's contracture. He opened and freshened the ulnar 
fracture and then tried to reduce the head of the radius but was 
unable to do so, although the capsule of the elbow-joint was opened. 
The head was excised and the ulna was wired, but improvement was 
very slow. Another interesting case was reported by Stetten,^ of 

fracture of the ulna at the upper and 
middle third in a nineteen-year-old 
boy. This was accompanied by for- 
ward dislocation of the radial head 
and paralysis of the radial nerve. 
On operation it was found that the 
head of the radius had pushed inward 
the two divisions of the musculo- 
spiral, and when the radial and pos- 
terior interosseous were freed and the 
head resected a perfect result followed 
within three years. (See Dislocations 
of Head of Radius.) 

The literature contains about 140 
cases of fracture of the ulna compli- 
cated by dislocation of the radial 
head, so that all cases of the latter 
injury should be scrutinized for the 





Fig. 281. — Transverse fracture of the 
ulnar shaft with avxilsion and wide dis- 
placement of the radial epiphysis. 



Fig. 282. — Transverse fracture of 
the lower part of the ulnar shaft. No 
separation. Cause, direct violence. 



fracture and vice versa. The question of treatment is an important 
one to decide on at once. If the radial nerve is involved, it must be 
freed and the head of the bone resected or put back in place, and 
the fibrous capsule of the elbow-joint torn from the capitellum and 



Ann. of Surg., Ivii, 266. 



2 Ibid., xlviii, 275. 



FRACTURES OF THE SHAFT OF THE RADIUS 



40: 



ulna, is loosened and swung over the head to hold it in place. Five 
cases have been operated on at once, 26 after an interval of many 
months. The early operation with resection of the head gives the 
best result. 

Fracture of the ulnar shaft when much displaced can usually be 
retiu-ned by digital pressure between the two bones. Traction has 
little influence on the distal fragment as long as the radius is intact. 
Operation is rarely if ever indicated to restore alignment, and simple 
reposition is sufficient. The radial flexion at the wrist (adduction) 
may help hold a short lower fragment in position by help of traction 
of the external wrist ligaments. Splints described in fracture of both 
bones of the forearm are used to maintain the position of the ulna. 




Fig. 283. — Buckling fracture of the 
lower end of the radius above the epi- 
physeal Hne. Green-stick fracture of 
the ulna from longitudinal compres- 
sion. Ulnar stvloid also broken. 




Fig. 284. — Healed fracture of the radius. 



Rarel>', a position of supination is indicated when the ulnar fragment 
is displaced far toward the radius, and a sling, which presses on the 
ulnar side of the forearm should be avoided. 

Fractures of the Shaft of the Radius. — The shaft of the radius 
alone is broken more frequently than it was formerly thought to be. 
In the statistics given on page 454 it is found that the shaft or head 
alone was concerned 158 times out of a total of 826 fractures. Direct 
violence, or indirect violence of a twisting character accounts for the 
majority of these injuries, but indirect violence from falls on the hand, 
giving pressure in the longitudinal axis of the bone, causes a small 
proportion. The buckling fractures (see Fig. 28^^) are excellent ex- 
amples of this mechanism. 



468 



FRACTURE OF THE FOREARM BONES 



INliisciilar action may also act when the hand is fixed or forcibly 
rotated while the muscles are acting in the opposite direction. 

The plane of fracture may be of 
any type, according to the cause; 
it is commonly transverse or 
oblique and is rarely comminuted. 
Displacements vary; in a trans- 
verse fracture there may be little 
more than an angular change in 
the axis of the radius at the. site of 
fracture, the bone ends holding 
apposition, because the periosteum 
or surrounding muscles fix them 
and the splint formed by the ulna 
is intact (Figs. 284, 285, and 286). 
In oblique or comminuted fracture, 
or transverse with displacement, 
the usual position is with an angu- 
larity forward and inward with a 
very small amount of overriding. 
Rotatory displacement can also 
occur between the two fragments 





Fig. 285. — Comminuted fracture of the 
radius with displacement. 



Fig. 286. — Comminuted fracture low 
down in the radial shaft; fragments held by 
periosteum. 



with very little angularity or evidence in the roentgenogram. This is of 
importance in those fractures above the insertion of the pronator teres, 



FRACTURES OF THE SHAFT OF THE RADIUS 



469 



attention to which was caUed by Lonsdale,^ and to which I made reference 
in speaking of fractures of both forearm bones. When the Hne of frac- 
ture is above the pronator teres muscle, the biceps tends to supinate 
the upper fragment and draw it forward. If union occurs with the 
upper fragment in this position, we should expect loss of supination 
of the forearm; hence in this type we dress the arm in supination. 
Fracture of the middle third, or just above the attachment of the pro- 
nator quadratus, is followed by the pulling of the upper fragment 
into outward rotation and abduction, while the pronator quadratus 
draws the upper end of the lower fragment toward the ulna. This 
must be guarded against union which will restrict the amount of 





Fig. 287. — Oblique fracture of the radius 
viith. angular displacement. 



Fig. 



288. — Lateral view of healed 
fracture of the radius. 



supination, and the arm is splinted in a position of supination which 
gives the greatest distance between the two bones, and in addition 
the hand is strongly adducted so that the pull of the external lateral 
ligament at the wrist will hold the lower fragment away from 
the ulna. It is impossible to have great overriding unless the ulna 
is also broken or dislocated out of position at the wrist (F'igs. 287 
and 2SSj. 

Symptoms and Diagnosis. — Localized tenderness, an apparent angu- 
larity, loss of function in the forearm with crepitus on rotation, 
give ample evidence of fracture. The ulna is felt along its whole 
length and found uninjured. The patient's hand is grasped by 



1 London Medical Gazette, 1832, ix. 



470 FRACTURE OF THE FOREARM BONES 

the corresponding hand of the examiner and the forearm is 
rotated. This reveals crepitus and the fact that the head of the 
radius does not rotate with the rest of the shaft, if complete frac- 
ture exists. 

Treatment. — Treatment varies in accordance with the site of frac- 
ture as suggested above. When the break is above the insertion of 
the pronator teres, the forearm should be held in supination at right 
angles to the arm and a moulded plaster splint applied which envelops 
two-thirds of the forearm circumference, extending from the wrist 
to the axilla; or two moulded plaster-of-Paris splints may be used, 
one on either aspect of the forearm, extending well above the 
elbow. Manipulation and extension after the placing of the arm 
in supination may succeed in getting the fragments into perfect 
alignment. 

In fracture in the middle of the bone the indications are similar to 
those for treatment of fracture of both bones. The position midway 
between pronation and supination with the forearm at a right angle 
is the most comfortable to the patient. Angular deformities are 
carefully corrected by slight pressure to bring the shaft of the radius 
in a straight line and a moulded plaster splint or the well-padded 
board splint used in both bone fractures, is applied. Fractures just 
above the insertion of the pronator quadratus muscle should be 
dressed with the arm in full supination and the hand in adduction 
to obtain the pull of the external wrist ligaments to hold the lower 
fragment out from the ulna. To accomplish this Alexander^ has" 
advised an internal lateral pistol splint on the forearm for holding the 
adduction of the hand and an anterior angular splint on the arm and 
forearm for holding the forearm in supination. This permits muscle 
relaxation in the forearm by bringing the bones into the same plane 
and parallel to each other. Twelve to fourteen days in this position 
permits bony union to start, and then the forearm can be released 
from its supination and gently splinted in a more comfortable and 
normal position. The splints should be kept on about five weeks, 
massage being started in the fourth week. No rotation exercises are 
advisable until early in the fifth week. Some deformity of an angular 
character is a common result, especially if the instructions as to supina- 
tion are not followed. In children this may not interfere seriously 
with function, but in laboring adults the loss of rotation or supination 
causes permanent partial disability. 

Lack of bony union is seldom seen. Lusk^ records a case of fracture 
of both forearm bones in which the radius failed to unite because a 
piece of muscle lay between the ends of the fragments. He per- 
formed open operation and did a wiring which involved but one side 
of the bone, passing through cortex and medulla, each end of the 
wire being fastened to its respective fragment alone and serving to 
make approximation in the longitudinal axis. 

1 Ann. of Surgery, Iv, 877. 2 j^id., liv, 255. 



COLLES'S FRACTURE 



471 



The forearm splints should come nearly to the ends of the fingers 
as in the cases of fracture of both bones, to prevent the unsupported 
weight of the hand from favoring a recurrence of deformity. 

In very muscular laboring adults, in instances where angular 
deformity cannot be satisfactorily reduced by manipulation or where 
rotatory displacement threatens loss of function, open operation with 
fixation by intramedullary or inlay bone graft should be done. Plating 
in the forearm does not seem advisable under ordinary circum- 
stances. By slight incisions of the interosseous membrane the ends 
of the fragments can be sufficiently drawn out so that a small bone 
peg can be inserted into the medulla. In the radius the medulla need 
be reamed out but little. Wiring is also performed in some cases. 

Colles's Fracture. — Colles first described fracture at the lower end 
of the radius in 1814^ and although he confused it slightly with dis- 
location of the wrist, which was supposed to be much more common, 




Fig. 289. — An ordinary 
Colles's fracture. The plane 
is obHque, there is slight 
impaction. Note the axial 
deformity in the ^^Tist. 




Fig. 290. — Lateral view of reversed Colles. Note 
the displacement upward of the distal radial frag- 
ment, producing the silver-fork deformity. 



his name has been rightly applied to this injury since better observa- 
tions on dislocation of fresh cases has led to definite knowledge on 
the subject. Roentgenograms have added to our knowledge of these 
fractures, and their character is well understood from the standpoint 
of site and displacement, but controversy still exists as to the exact 
mechanism of production. The plane of fracture is nearer the wrist- 
joint than was formerly believed, a large proportion being less than 
an inch from the articular surface, with an average of about one-half 
inch. The direction is transverse in most cases, but it may be oblique 
from the median side of the radius across into the joint, or it may 
be oblique in the anteroposterior plane (Figs. 289 and 290). Cotton^ 

' Edinburgh Med. and Surg. Jour., x, 182. 

2 Dislocations and Joint Fractures, 1910, p. 325; .Jour. Boston Soc. Med. Sci., ii, 171; 
Ann. of Surg., -\ugust, 1900. 



472 



FRACTURE OF THE FOREARM BONES 



made a series of experiments bearing on the line of fracture and con- 
cluded that separation by arrachement tends to produce transverse 
fractures very close to the joint, but that those artificially produced 
were more often oblique forward and upward. 

Comminution is common; generally the lower fragment suffers the 
most, becoming split and flattened out, mushroom fashion; or the 
upper fragment is split by several lines of separation, and shells of 
cortical bone are torn or splintered out of the diaphyseal surface. 





Fig. 291. — Colles's fracture, 
lower fragment mushroomed into 
upper with little axial change. 



Fig. 292. — Colles's fracture with impaction 
and lateral displacement. The ulnar styloid 
has been broken off and the phalanx of the 
thumb also. 



Displacement. — The low^er fragment, loosened from the radius, may 
be forced into a new position as follows (Fig. 291) : 

(1) It may be comminuted and crushed and mushroomed onto 
and into the end of the diaphysis by impaction without suffering any 
change in its axial relations, so that merely a foreshortening of the 
radius and a broadening of its articular surface results (Figs. 292 
and 293). 

(2) There may be angular rotation of the intact or split lower 
fragment in either a lateral or anteroposterior plane or a combination 
of both. These oblique lines of separation may run: 



COLLES'S FRACTURE 



473 



(a) Upward and forward clear through the bone, without causing 
any forward dislocation of the lower fragment (Fig. 294). 

(6) Upward and backward, a common variety. 

(c) Upward and outward. 

This obliquity is not sharp, seldom being greater than 30 to 35 
degrees, and all forms are accompanied by the rotation upward and 
outward of the lower fragment, except in rare instances w4ien the lower 
fragment is displaced in exactly the opposite direction, namely, down- 
ward and backward. It is this rotation which gives the appearance 
of outward displacement of the whole wrist (Figs. 295, 296, and 297). 

The usual displacement is rotation of the lower fragment. Its 
articular surface is turned slightly upward, and it comes to lie on a 





Fig. 293. — Nearly transverse Colles's 
fracture with an additional fracture 
plane running into the wrist-joint. 



Fig. 294. — Colles's fracture with a 
fragment displaced from the palmar sur- 
face of the radius. 



higher level than the end of the radius, being at the same time impacted 
into the diaphysis. The styloid process is turned upward somewhat 
and is found on a higher level than in the normal wrist. Avulsion or 
fracture of the ulnar styloid mav accompanv this condition (Figs. 
29S, 299, and 300). 

('-]) There may be separation through the epiphyseal line, especially 
in children under sixteen years, with all grades of distraction from 
a slight starting of the lower fragment out of position to complete 
displacement in accordance with the usual findings, as under (2). 

No two Uolles's fractures are alike. Although fresh specimens 
caused by the usual mechanism can be obtained, the injury seldom 
leads to amputation, and postmortem examination of the wrist is 
seldom done. If this fracture is incidental to other injuries which 



474 



FRACTURE OF THE FOREARM BONES 



cause cleath, the method of its cause is extraordinary violence as a 
fall from a great height. 




Fig. 295 Fig. 296 Fig. 297 

Fig. 295. — Fracture of radius, longitudinal split with lateral separation. Note that a 

small fragment has been broken off the navicular bone. 

Fig. 296. — Impacted and laterally displaced CoUes's fracture with longitudinal cracks. 
Fig. 297. — A confusing type of wrist fracture found in children. Complete fracture 

of the ulna and a complete plane through the radius without separation. 




Fig. 298 Fig. 299 Fig. 300 

Fig. 298. — Epiphyseal separation of both bones at the wrist in a child. Slight dis- 
placement. 

Fig. 299. — Epiphyseal separation and fracture of the ulnar styloid in a fourteen-year- 
old boy. 

Fig. .300. — Epiphyseal starting caused by fall from a swing, girl, fourteen years old. 
Both wrists the same. 



Study of the different types of the displacenient as given in the 
reproduction of the roentgenograms will impress the reader with the 
fact that posterior displacement of the lower fragment is not very 
marked. Tilting and comminution are common, and impaction or 



COLLES'S FRACTURE 



475 



driving of the loAver piece into the upper fragment is the usual finding. 
This displacement conforms to the clinical deformity. The hump-like 
mass from shortening of the radial side of the wrist and the promi- 
nence into which this shortening throws the ulnar styloid with seeming 
deformity on the outer side are manifest, because the carpal bones 




Fig. 301. — Impacted Colles with long 
linear planes of separation in the radius 
and fracture of the na\-icular. 






Fig. 303. — A lateral \'iew of an epiphy- 
seal separation of both bones at the wTist. 
Note the upward displacement of the lower 
radial fragment. 



Fig. 302. — Epiphyseal separation 
and fracture of the inner margin of 
the radius with slightly impacted frac- 
ture of the lower end of the ulna in 
a child. Note the upward displace- 
ment of the radial epiphysis. 



maintain their articular line and relation to the forced-up articular 
surface of the radius. 

The accompanying pathology is as follows: The wrist ligaments 
are seldom torn completely but may be lacerated in Colles's fracture. 
From the shortening of the radial side of the wrist the external lateral 



476 



FRACTURE OF THE FOREARM BONES 



ligament attached to tlie ulnar styloid may be torn off, or its angle of 



clianged 



,)UH cnanged, or it may wrench ofi* the end of the styloid process, 
maintaining its own fibers intact. This last condition appeared in 
1 5 ont of 54 cases in 1914 ; fracture of the carpal navicular accompanied 
1 case (Figs. 301, 302, 303, and 304). The radio-ulnar ligament is torn 
in some cases sufficiently to permit some upward dislocation of the 
head of the ulna, which becomes therefore more prominent than 
it would be from the radial damage alone (Fig. 305). Hemorrhage 
into the tissues from the fracture site does not occur early unless the 
periosteum is torn open, otherwise a subperiosteal hematoma slowly 
forms, which greatly increases the seeming deformity. Later evidence 
of hemorrhage along the interosseous ligament as far as the elbow is 





Fig. 304. — A back-fire injury from 
an automobile. The plane of frac- 
ture tends to select the epiphyseal line. 



Fig. 305. — A similar injury from a fall. 
The palmar side of the bone alone seems 
separated. 



noted in the ecchymoses which appear on the surface. These may 
also spread down into the hand. Blood is seldom effused into the 
tendon sheaths crossing the wrist; a serous effusion may slightly 
distend them but true hemorrhage into them is very rare, as it takes 
place alongside and outside. Resulting stiffness in the fingers and 
wrist is not caused so much by damage of the tendons or their sheaths 
from the trauma as it is by shortening of the muscles and the peri- 
synovial structures from long immobilization and disuse and incom- 
plete reduction of bone fragments. Forcible effort to break up this 
stiffness may lead to reformation of adhesions and make the result 
worse. Open Colles's fractures are almost unknown. In them the 
upper end of the radius may be driven out of the soft parts, or the 
flislocated head of the ulna may come through the skin, sometimes 



COLLES'S FRACTURE 



477 



tearing the median nerve. Xerve injury or pressure is a rare com- 
plication. The median nerve has been reported as showing evidence 
of delayed injury.^ It is sometimes stretched over the ulnar head. 
Periosteal stripping and laceration are common, and in old healed 
fractures with posterior displacement the stripping of the periosteum 
from the shaft causes callus to be deposited, so that a large bony mass 
is formed which enliances the deformity. Pieces of detached bone 
from the styloids may lie free in the wrist and never become attached 
to the parent bone. Movements and the play of tendons about these 
fragments result in their developing into sesamoids (see Figs. 306 
and 307). The triangular fibrocartilage may also be torn. When 
this fracture heals unreduced, thickening of the ^mst capsule, inhibi- 
tion of motion, and loss of power in the hand and fingers follows. 




Fig. 306. — Old fracture of ulnar sty- 
loid. The fragment never became 
united and has formed a sesamoid bone. 




Fig. 



307. — Formation of multiple sesa- 
moid after wrist fracture. 



In a young person time will overcome much of this disability, but in 
elderly people the prognosis for complete recovery is bad even with 
further treatment looking toward a better reposition of the fragments. 
The impaction of the lower fragment into the diaphysis causes some 
bone absorption if it is not reduced at once, and even in early reduction 
the cancellous material ma\' have been crushed and shortened, so 
that full length and exact original conformity of the bone can never 
be restored. 

Epiphyseal separations, if replaced, often lead to no permanent 
interference with growth, but on the other hand, an unfavorable result 
may follow. A case was reported by Andrews^ and also by Stimson. 
Waechter^ cites an instance in an eleven-year-old boy whose parents 



1 Blecher, Deutsch. Ztschr. f. Chir., xciii, 34. 

2 Ann. of Surg,, xxxv. 



3 Ibid., xlviii, 115. 



478 FRACTURE OF THE FOREARM BONES 

noticed a gradual adduction of the hand and projection of the ulna 
two years after he had suffered a Colles's fracture which had been 
properl}' reduced. A study of the roentgenogram of this case shows 
that the epiphysis had become bony and had probably therefore lost 
its growing function. Bruns found 25 cases of retarded growth in 
the radius in 81 instances of different epiphyseal separations/ and 
Hutchinson has also recorded cases of similar radial deformity .^ I 
have 5 cases under observation at this time, some of them five years 
since fracture; 1 of them was operated on for deformity and none 
have yet developed any interference with growth. 

Causes. — Colles's fracture results from one's falling on the out- 
stretched and hyperextended hand, generally while walking, although 
it may follow falls from a greater height. In adults and elderly people, 
trips on rugs, uneven ground, overbalancing on wet or slippery walks 
which result in falls cause the fracture. There has been much con- 
troversy as to the exact mechanism of the usual type of displacement, 
and the methods of application of the force can be expressed under 
three headings : 

1. Splitting or crushing by force transmitted from the carpal bones. 

2. Radius yielding at a weak point at or above the epiphyseal area 
when the lines of force of the trauma break up. 

3. Cross strain exerted at the insertion of the capsular ligaments 
in the juxta-epiphyseal area on the lower end of the bone. 

In another place^ attention has been called to the mechanism of 
sprains and fractures at the lower end of the radius and the author 
believes that the third heading demands more recognition in the 
mechanism in most cases than it has ever had. If the force is trans- j 
mitted directly through the carpal bones it is odd that these bones 
are so seldom damaged, granting their ability to take up pressure 
stress on account of their number and arrangement. The breaking 
up of the causative force into its component parts has less to do with 
the tilting and displacement backward of the lower fragment than the 
pulling stress of the tense capsular ligament on this portion of the 
radius in response to the tension from the attachment below to 
the carpal bones. Sir Astley Cooper's experiments, in 1833, and Boun- 
chet's, in 1834, showed that transverse fracture at the lower end of 
the radius could be produced by this ligamentous pull (the author 
does not believe it is a true avulsion except in those cases where a 
small lip on the surface of the bone is pulled out) (Fig. 308), but the 
experiments also produced rupture of the anterior ligament and dis- 
location or fracture of the carpal bones. Consequently, such an 
authority as Stimson, while admitting that the fracture may be caused ' 
by this means, does not consider it the usual mechanism because of 
those other injuries which happened in the cadaver about as often 
as fracture of the radius. 

1 Langenbeck's Arch., Berlin, 1881-2, 

•^ Arch. Surg., London, 1892-93. 

^ Speed, Surg., Gynec. and Obst., August, 1913. 



COLLES'S FRACTURE 479 

There has been left out of consideration the fact that those who 
sustain this fractiu'e are Hve people whose strongest instinct is self- 
preservation. As they feel themselves falling they unconsciously 
throw out a saving hand and receive the impact on the palm with 
the wrist as stiff and rigid as it lies in the power of the many tendons 
and ligaments encasing the joint to render it. Some force must be 
carried to the end of the radius by the carpal bones, but the cartilage 
in the wTist-joint and the separation and distribution of the numerous 
wrist bones take up some of this force in a cushion-like manner, and 
the greatest burden is borne by the stronger-than-bone ligaments, 
the pull of which takes place at their points of insertion in the radius. 
If the fall is not so well guarded or the individual is old and has 
rarefied bones, we expect the direct carpal pressure to cause more 
damage, as evidenced by great comminution, more impaction or 
injury of the carpal bones. What in one case will give merely a sprain 
with ligamentous damage, in another will cause epiphyseal or sprain 
fracture of the styloid process, with little displacement and no com- 
minution. This cross strain, force of which is received by the palm 
as the hand is extended, is exerted 
just above the end of the bone by 
the anterior and lateral ligament. 
As the hand is bent back the liga- 
ment is put under extraordinary 
stress, and the lower fragment is 
broken. In the so-called chauf- 
feur's fracture a like mechanism, 
caused by the sudden forcible back ^^^ 308.-Avuision of a portion of 

jerk of the crank handle, puts this the dorsal lip of the radius by liga- 

unexpected and powerful strain on lentous pull. 
the lower end of the radius when 

the ligament is tense with the exertion of cranking, causing a trans- 
verse or diagonal fracture. 

If one takes first a juxta-epiphyseal strain which gives but slight 
evidence in the skiagram of the pulling-out strain caused by the trauma; 
follows through with more pronounced cases, first of sprain fracture 
involving a corner of the styloid process, then the more extensive 
injury cracking the bone nearly across the diameter of the lower end ; 
and finally an impaction of the two fragments after this cracking 
across, with little if any silver-fork deformity or anteroposterior dis- 
placement, one finds that the fracture leads on to an ordinary Colles 
in accordance with the three methods of mechanism mentioned. 

Recapitulated, the mechanism seems to follow in this order: fall 
on hand pronated and probably abducted, tearing stress of lateral 
and anterior ligament which is tougher than the bone to which it '-; 
attached, tearing or splitting off of corners or whole diameter of the 
radius, continuation of force driving lower fragment up into shaft 
by transmission of line of force from wrist bones, and finally cjm- 
minution by a breaking up of the line of force as trauma ceases 




4S0 FRACTURE OF THE FOREARM BONES 

Symptoms and Diagnosis.— The most striking symptom is a sign, 
the (let'ormity. The wrist bones seem dislocated backward, and a 
hump-hke mass takes the place of the normal straight line which 
can be drawn from the forearm across the wrist to the base of the 
fingers with the hand in extension. In the normal wrist a straight 
edge laid on the forearm w^th the hand in extension touches at all 
points. With the deformity following Colles's fracture this test can 
not be applied because of the so-called ''silver-fork" curve at the site 
of fracture, the distal portion of the radius having been displaced 
backward. There is also pain in the wrist, tenderness on pressure 
over the break and frequently over the ulnar styloid, and inability 
to grasp with the usual hand grip. Swelling follows and increases 
the deformity on the dorsum of the wrist, while on the palmar surface 
there appears also a bulging from the edema and hemorrhage and the 
projection of the upper fragment of the radius. The silver-fork 
appearance, as has been proved by roentgenogram, arises not so 
much from the actual displacement of the lower fragment, as from 
the swelling in the soft parts and the shortening of the radial side of 
the wrist with the tilting up of the joint surface of the radius. The 
ulnar styloid appears more prominent, and on comparison, of the 
sound and injured wrists it is noted that the styloid tip of the broken 
radius has been pushed up more nearly on a level with the ulnar 
styloid. In the well wrist it normally lies on a level some three-eighths 
inch lower. 

Crepitus may be entirely absent, as also abnormal motion, if impac- 
tion is present. To obtain these signs the examiner grasps the shaft 
of the radius in one hand and the lower end in the fingers of the other 
and by movement in opposite directions may obtain both findings 
at once. It is sufficient to find that this test elicits great pain. Pencil 
pressure down the shaft of the radius usually discovers the exact 
point of fracture through the pain produced, and attempts to hyper- 
extend the hand cause pain above the end of the radius. Flexion is 
usually much limited on account of the displacement, and the grasping 
power of the hand is reduced to nothing. 

Sprain fractures or linear cracks with no apparent deformity may 
give all the above-mentioned findings except the silver-fork appear- 
ance (Figs. 309 and 310). The finding of a recurring point of extreme l 
tenderness on the lower half-inch of the radius with the history of 
sufficient trauma leads to diagnosis of these lesser fractures. In 
doubtful cases of no legal importance a few days' wait will determine 
whether the injury is sprain or fracture, but in the meantime every • 
case should be treated as fracture, and the Roentgen examination 
should be made at once if there is liability. After a few days' rest ' 
a sprain will be much less painful, function will be returning or increased 
beyond that of the first examination, whereas in fracture even a mere 
crack will give the recurrent extreme tenderness and great delay in 
functional return. 

Colles's fracture must also be differentiated from fractures of both 



COLLES'S FRACTURE 



481 



bones near their lower end. Cojitusion and suhyeriosieaJ hemorrhage 
of the bones at the wrist which do not involve a change in the posi- 





FiG. 309. — Sprain fracture of lower 
end of radius. Note the involvement of 
the articular surface. 



Fig. 310. — Chauffeur's fracture of 
lower end of radius with some displace- 
ment. 



tion of the styloids are rare and have a swelling below the point of 
silver-fork deformity. Dislocation of the wrist backward likewise 
has a deformity lower than a Colles's fracture, 
and the two styloids are in normal position. 

Prognosis. — Bony union is almost invariable, 
in many cases too prompt, if the patient has 
not been seen at the time of accident and seeks 
advice after a few weeks for persistent loss of 
function in the hand. After a month the deformity 
is marked and it is very difficult to break up the 
union. Permanent deformity of varying degree 
exists in most cases except in youths, who may 
outgrow it readily. In adults, with the best re- 
duction possible, some shortening of the radius 
or tilting of the lower fragment, thickening of 
the wrist and prominence of the ulnar styloid 
can be expected (Fig. 311). These results are 
caused by comminution and difficulty of reducing 
the bone. Function is frequently very good when 
the deformity is quite apparent. After a year, if 
use is persisted in, the function should be as good 
as it will become, and although flexion may be 
limitefl on account of the tilting, use is painless 
and is very satisfactory. ^luch depends on the 
manner of reduction and the after-treatment. 
Farly mobilization with gentle massage and wrist 




Fig. 311. —Healed 
Colles's fracture. The 
silver-fork deformity 
persists. Note how 
the radial joint surface 
points downward. 



:u 



482 FRACTURE OF THE FOREARM BONES 

motions avoid swollen and stiffened joints in the fingers, which are 
largely the result of splint pressure. The use of the Roentgen rays 
helps to call attention to accompanying fractures and dislocations 
of the carpus. These should be treated early and disability charged 
to them and not to Colles's fracture if the wrist injuries are over- 
looked. 

Treatment. — As a preliminary step to treatment the surgeon should 
study the injury, comparing with the sound wrist to satisfy himself 
on the following points: comminution of the lower fragment as 
evidenced by the broadening, the degree of impaction ascertained 
by the apparent shortening of the radius and the inability to move 
the lower fragment by manipulation. The amount of backward 
displacement and rotation of the lower fragment upward or outward 
should also be determined. Women, children, and elderly people, as 
well as robust adults with much displacement and muscle spasm should 
be treated while under a light anesthesia. Gas is sufficient in most 
cases to ease pain and relax muscles, or the ether rausch is very 
efficient. 

Treatment consists in reduction. In the case of elderly persons or 
children under anesthesia, by grasping the wrist in both hands, and 
pressing the thumbs down on the lower fragment and up on the upper 
fragment one may quickly accomplish reduction. Impaction, stronger 
bones, or bulky muscles frequently demand more force and interlock- 
ing of the fragments. The surgeon grasps the patient's hand or wrist 
in his right hand and hyperextends it in an attempt to unlock the 
overriding and impacted lower fragment. Repeated vigorous motions 
of flexion and extension are necessary frequently for the gaining of 
the freedom of the lower fragment. If the rotation and displacement 
are backward and outward with impaction, a motion of circumduction 
of the hand in a wide arc usually frees the bone. When this is attained, 
the hand is brought into sharp flexion, while traction is made in the 
long axis, aided by pressure downward on the lower fragment. Lateral 
deviation is corrected by this same maneuver, aided by direct press- 
ure and adduction, and the hand is allowed to lie lax while the wrist 
is examined for persisting deformity. Persisting impaction which 
resists this force can be broken up by the operator grasping the wrist 
while it rests on his knee and rocking the fragments forcibly with the 
hands. 

Reduction must bring the displaced and rotated fragment down 
into place. When it does, the hand will lie laxly in a position of flexion 
if the forearm alone is supported, and the silver-fork deformity will have 
disappeared. Overreduction, forcing the lower fragment down below 
the line of the upper fragment and reversing the displacement, must 
be avoided. When reduced there is no tendency for the deformity 
to recur, and the styloids should have regained a normal relative 
height, the radial again being lower. 

The indication for splinting is then simple. The old pistol splints 
are of no value, as they attempted to hold the fragment in place, or 



COLLES'S FRACTURE 483 

to correct radial shortening by abducting the hand and using the pull 
exerted by the internal lateral wrist ligament. That fallacy has been 
fully exposed. No splint holding the hand in abduction will prevent 
radial shortening after the bone has been crushed, and the value of 
this position to maintain reduction was greatly overestimated and 
led to longer disability from the fingers being held in a cramped position. 

The easiest splint to use is one of moulded plaster extending on the 
forearm from the elbow to the base of the fingers with a pad over the 
back of the hand and also a pad over the lower end of the upper frag- 
ment and the ulna in front (palmar surface). This is applied and ban- 
daged on, the hand being held in a position of slight flexion with fingers 
free to move. This splint will make no constriction and is advisable 
for a few days to give the patient a feeling of security and to permit 
swelling to subside. It can be carried by a handkerchief sling about 
the neck, or, if the patient wishes to avoid attracting attention, no 
sling at all is needed, and the arm can be allowed to hang or be tucked 
into the coat when at business. Some surgeons rely so much on the 
reduction that they use no splint at all, merely strapping the wrist 
about with a broad band of adhesive. I believe the rigid splint does 
no harm when worn a short time and is advisable for the reasons give 
above. Wooden splints may be used. They should be broad, the 
dorsal splint extending from the elbow to the wrist, the palmar splint 
starting at the same level and extending to the base of the fingers. 
These are thoroughly padded, as for the moulded plaster splint, and 
are strapped together by adhesive. Piano or saddler's felt is better 
material for these pads than cotton, as it has more elasticity and does 
not get lumpy and out of place. Pressure of the splint and pads must 
be avoided over the dorsum of the upper radial fragment and the 
ulna and over the thenar eminence. 

The hand is inspected within a few hours for swelling, cyanosis, 
feeling of numbness and pain from pressure. As a rule the patient 
feels relief from most of his pain as soon as reduction is made, and 
with the light plaster splint feels comfortable in an hour or two. 
If any particular point of pain is complained of, the splint should 
be removed at once and pads and reduction investigated. 

After-treatment.— On the second or third day the splint is removed 
and the hand and forearm is lightly massaged, passive motion being 
given to the wrist. This is continued daily with a longer massage 
and instruction to the patient to exercise the fingers much of the time. 
After eight or nine days the splint is removed during the day and put 
on at night, and after fourteen days no splint is needed. The wrist 
is then strapped or bandaged snugly, and active motions are advised. 
I'nion is firm, and the wrist is in good condition in one month, without 
finger swelling or stiffness except that incident to the immediate 
result of the trauma. A leather wrist strap can be worn after active 
use is begun until the ligaments regain tone. 

Pain and weakness in the ulnar side may be a persisting symptom. 
This is caused by an imperfect repair of the external wrist ligaments 



484 FRACTURE OF THE FOREARM BONES 

or a slight dislocation of the hand, and strapping with rest and time 
will improve the result. If limitation in flexion of the wrist is found 
after several weeks while extension or hyperextension is greater than 
normal, the effect probably results from a change in the plane of the 
wrist-joint through tilting of the lower fragment. The same explana- 
tion is offered for a limited adduction or a too great abduction. These 
are favored by rotation of the lower fragment and the articular plane 
rather than by any great amount of broadening of the wrist or separa- 
tion of the two bones at the lower end. Reduction may be as perfect 
as can be accomplished with no return of the gross deformity, yet in 
six or eight weeks the patient will come complaining of poor function, 
and the surgeon will feel that possibly he is at fault. This is not so; 
considering the character and size of the wrist-joint, the crushing 
of the radius, and other points, such as backward displacement and 
rotation, outward rotation of the lower fragment and radial shorten- 
ing, if the silver-fork deformity is obliterated and the lower fragment 
is returned into the best position obtainable at the time of reduction, 
no fears should be felt for considerable functional return in due time. 
After satisfactory treatment, it is usual to find a slight prominence 
and forward displacement of the ulna and some flattening of the 
lower radial arch as an end-result. More displeasing deformities 
result in cases caused by extreme violence when the fragments are 
badly comminuted and the splints do not hold firmly, or when in 
senile bones the radius is crushed so that on reduction of the lower 
fragment a gap persists between it and the shaft on the outer surface. 
If the ulna has suffered marked displacement, the deformity of its lower 
end may be unpleasant and even increased if use is permitted before 
strong ligamentous healing has followed. This healing may be greatly 
delayed because of poor personal reparative power. 

The indications for operative treatment are narrow. Practically 
every fresh case can be reduced by manipulation, and I have never 
operated on one. If a case is neglected or not reduced and after a few 
weeks' manipulation fails to establish a satisfactory position of the 
lower fragment, reduction by open operation should be done. Uncor- 
rected epiphyseal separations or fractures in youths, unsightly deform- 
ities or restricted function in adults, are also good grounds for open 
replacement. Much can be promised as to decrease in deformity, 
but the matter of function is not so happy of solution. 

In younger people a lateral incision over the fracture, with retrac- 
tion of the tendons, exposes the bone through a two-inch incision. A 
sharp chisel, equalling the diameter of the bone, is then driven through 
the site of fracture, and by manipulation the deformity is corrected 
so that the lower fragment lies in good position. In adults, especially 
long-standing cases, with callus formation beneath the stripped-up 
periosteum, a dorsal incision is made. All tendons are retracted, and 
after the periosteum is reflected from the radius the excess callus is 
chiseled away, the bone cut through, and the lower fragment replaced. 
Closure of the periosteum follows. 



COLLES'S FRACTURE 485 

Deformities of the lower end of the uhia rarely demand operative 
treatment. Efforts to strengthen or suture the lateral ligament too 
often end in failure, and a loosely displaced fragment of styloid process 
does not demand removal unless it interferes with joint motion or 
causes pain. If the loAver end of the ulna has great displacement, 
there may be indication to resect it . (See ]Madelung's deformity.) 

Other fractm*es at the ^^Tist are: Reversed CoUes's fracture, that is, 
the usual displacement of the lower fragment is downward toward 
the palm, opposite to an ordinary Colles. These fractures are uncom- 
mon and are due either to direct violence on the dorsum of the wrist, 
which drives the lower fragment down, or to falls on the back of the 
hand. In these cases flexion is greater than normal, extension is 
limited, and the relation of the styloid processes may be the same as 
in a Colles. Above the \^Tist-joint the shaft of the bone causes a 
prominence, because the lower fragment is depressed, and the deformity 
may be mistaken for the silver-fork variety. On the palmar side 
there is a sharp projection caused by the pushing out toward the palm 
of the lower fragment. The other findings are like those of a Colles 
in regard to impaction, shortening, etc. Reduction is accomplished 
by manipulation as in the Colles, effort being directed toward raising 
the fragment up into its normal position in line with the radial axis. 
It is possible that too violent attempts at reduction of a CoUes's 
fractiu-e might force the lower fragment down into this opposite 
position. 

Fractures of both bqnes at the wrist, also uncommon, give the same 
findings as a Colles, with a lower and more flail-like T\Tist. This 
injury is to be diagnosed by the finding of the plane of fracture in the 
ulna and is differentiated from dislocation of the ^\Tist through the 
fact that the styloid processes bear a normal relation to the wrist 
bones. Treatment is that given for Colles's fracture, and great care 
must be observed to keep the hand in line of the forearm axis. Palmar 
and dorsal splints on the forearm, extending to the finger tips, are 
necessary to maintain immobility. Disability is three to four months. 
Barton's fracture, as described by him,^ consisted in a breaking off 
of the posterior tip of the articular end of the radius at the wrist. 
This fracture was supposed to be frequent, particularly in wrist dis- 
locations, as a small fragment of the radius was pulled out by the 
ligaments and carried away by them as they lost their hold on the 
raflius. These fractures we know now are fairly common, they accom- 
pany sprains of the wrist, and the fragment is seldom widely displaced 
(see Fig. 308). Diagnosis is made by a localized point of tenderness 
and circumscribed swelling, which persist. They must be differen- 
tiated from injuries of the scaphoid and semilunar bones (which see). 

Fractures of the radial and ulnar styloid processes are common (Figs. 
ol2, 313, and 314). Many of them involving the radius are the Chauf- 
feur's fracture, caused by a sudden back jerk from back firing of a 

' Med. Exam., 1838, p. 36.5. 



48G 



FRACTURE OF THE FOREARM BONES 



gasoline engine when it is being cranked. The sudden violent jerk 
pulls out the corner of the bone where the ligament is attached, or 





Fig. 312. — Fracture of both 
styloid processes. Carpal bones 
intact. 



Fig. 313, — Fracture of both styloids, fracture 
of the inner edge of the radial surface and of the 
navicular. An excellent illustration of wrist 
injury from fall on the hand. 





Fig. 



314. — Fracture of the ulnar 
styloid alone. 



Fig. 315. — Fracture of the ulnar styloid,^ 
fragments ununited and becoming sesamoid 
in character. 



the transmitted violence from the carpus cracks it off. The line of 
fracture is usually oblique, the separation very little, so that a dried 
Roentgen-ray plate must be carefully searched for the evidence. The 



COLLES'S FRACTURE 487 

same type of fracture, which is so much hke Colles's, is caused by 
falls and direct violence. 

Treatment is rest on a palmar splint for two or three weeks. Isolated 
fracture of the ulnar styloid is also found. It is caused by direct 
violence or fall on the adducted hand. Fracture of this process also 
accompanies injuries of the carpus. The surgeon may be able to 
palpate the loosened fragment or find pain in the styloid region. I 
have seen several cases where the process was broken and bent down 
with no separation, uniting with the head in the new position. Some 
pain and permanent stiffness result. Other cases of separation probably 
never unite (see Fig. 315). , The small fragment becomes sesamoid 
in character. This I have also observed once in a fracture of the radial 
styloid. 

Treatment consists in holding the hand in abduction on a palmar 
splint. If no reduction can be obtained and the displaced fragment 
gives pain or interferes with joint motion, it must be excised. 



CHAPTER XVIII. 
DISLOCATIONS OF THE ELBOW. 

In the discussion of fractures of the humerus at the elbow the 
practical points of the anatomy of the elbow have been reviewed. 
One must recall that the external condyle of the humerus articulates 
with the head of the radius by means of the capitellum and that the 
lips of the trochlea with the help of the lateral ligaments, guard and 
direct the movements between the ulna and the humerus. The joint 
capsule is attached above the coronoid and olecranon fossse in such a 
manner that it blends with the periosteum, while on the inner side 
it is attached to the prominent lip of the trochlea, and the internal 
condyle lies without the joint. The location of the points of the elbow 
are also important; with the arm in full extension, the points of the 
external and internal condyles and olecranon assume almost a straight 
line, the olecranon lying slightly higher, while in flexion the olecranon 
point forms almost an equilateral triangle with the other two, lying 
over an inch below and between them slightly nearer the internal 
condyle. These points can be made out even in the presence of great 
swelling, and, supplemented by palpation of the head of the radius 
when the forearm is rotated, give definite information of the condition 
of the elbow. Every elbow examined must be compared with the 
opposite one that individual peculiarities may be noted. The olecranon 
can be identified by palpation of the ulna in the forearm up to the 
joint and the sharp projecting point of the internal condyle, and 
the ulnar nerve can be recognized by being rolled under the finger. 
Edema and swelling about the joint may be reduced by gentle massage 
sufficiently to permit diagnostic examination, but in some cases the 
arm must be put at rest in a sling with cold applications until the 
swelling subsides. 

Frequency. — In seven and a half years at the Cook County Hospital 
the records show an admission of 796 cases of dislocation, of which 53 
were of the elbow. In the last eighteen months of this period there 
were 16 cases, 13 in males, 3 in females — 4 being in children. This 
bears out other statistics, namely, those of Kronlein, who is quoted 
by Stimson in statistics covering 109 cases. Males predominate at 
a ratio of 4 to 1, and children often suffer the luxation, because their 
arms are more frequently hyperextended in falls. Adults in the 
third and fourth decade are more likely to fall with the arm in slight 
flexion held by the strong muscles, so that the violence is carried 
indirectly to the shoulder and results in shoulder dislocation or frac- 
tures of the clavicle. Of the 16 cases mentioned, 9 were reduced 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 489 

promptly, 2 refused treatment, 1 refused operative treatment, 1 child 
suffered gangrene and amputation, and 3 cases were operated on. 

Types of Elbow Dislocations. — Any elaborate classification of elboAV 
luxations is confusing for practical purposes. The following simple 
ones, depending on the involvement of one or both bones of the 
forearm, is convenient: 

Dislocation of both bones backward, lateral, forward, and divergent. 

Dislocation of the radius alone. 

Dislocation of the ulna alone. 

All types of elbow dislocation may vary in extent, according to 
the strength of the primary violence and the secondary position 
assumed when the violence continues to act after the joint is displaced. 
The causes of these luxations are the same, whether they are complete 
or incomplete, and we shall consider them all together, making special 
reference to such types only as are recognized clinical entities. 

BACKWARD DISLOCATION OF BOTH FOREARM BONES. 

This displacement is the usual one at the elbow and is caused by 
falls on the outstretched hand with extension and abduction of the 
forearm. Both adults and children are subject to this displacement, 
the ultimate position of the luxated bones depending on what direc- 
tion the force pushes them in and whether the body weight twists 
the forearm as the patient falls — the hand remaining fixed. Direct 
violence applied above the elbow causes fracture of the humerus, and 
applied on the forearm in blows and torsion strains may rarely cause 
elbow dislocation. The mechanism is one of leverage. Hyperextension 
with or without abduction causes the oleeranon point to impinge 
against the humerus. This point becomes the fulcrum of the lever, 
the power is the weight of the falling body above, and the weight is 
the resistance of the anterior and lateral ligaments of the joint, which 
become tense and are strained to the breaking point, the forearm 
bones slipping out posteriorly into dislocation. If the forearm is in 
some abduction with the hyperextension, we should expect the first 
and greatest tearing evidence to be manifested over the internal con- 
dyle, the capsule and ligament rupture starting there. It often happens 
that the tip of the condyle is torn off together with the insertion of 
the flexor muscles of the forearm. Experimental work on the cadaver 
imitating falls on the outstretched hand verifies the tearing of the 
anterior ligament on the internal side when the hand is supinated. 
The ligament and capsule give at this point, the elbow-joint is depressed 
inward, and the lower end of the humerus is shoved down in front of 
the head of the radius and the coronoid of the ulna until the luxation 
is accomplished. 

Pathology. — The tear in the anterior ligament has been described 
as always occurring high up near its insertion on the humerus, the 
hne of separation running inward through the internal lateral liga- 
ineiit in the usual position of abduction. The cases of unreduced 



490 



DISLOCATIONS OF THE ELBOW 



posterior dislocation of the forearm which I have operated on do not 
verify this statement, as I find that the anterior position of the capsule 
is torn low enough down to leave a small flap which hangs down over 
the articular surface of the joint and by its adherence and interposi- 
tion offers a real obstacle to reduction. On theoretical grounds one 
would expect the ligament to tear at a lower level than near the point 
of insertion into the humerus, because the point of greatest stress is 
near the radius and ulna, and the insertion of the ligament into the 
periosteum of the humerus is its strongest point. The internal lateral 





Fig. 316. — Fresh dislocation of the 
elbow backward, the coronoid lying under 
the olecranon fossa. 



Fig. 317. — Anteroposterior view of 
an old dislocation backward, the radial 
head lying beneath the external condyle. 



ligament is similarly torn ; the external lateral ligament may be intact 
or stripped up from the humerus, lifting the periosteum. The orbicular 
ligament about the head of the radius is intact. 

The displacement of bone is not uniform in all cases. Both bones 
may be slipped completely and directly backward, the coronoid lying 
under the olecranon fossa or against the edge of the trochlea (Fig. 
316). The greater the bone displacement, the greater the capsular 
and ligamentous tear. When abduction has had a prominent part 
in the luxation, the radial head may remain in partial contact with 
the capitellum, while the coronoid rests against the under surface of 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 491 

the trochlea, but usually both bones are displaced well backward, so 
that the head of the radius lies beneath the external condyle (Fig. 
317). Rarely the coronoid comes to lie against the posterior surface 
of the external epicondyle and the radial head lies on the outer side. 
The long axis of the forearm consequently varies within 15 degrees 
on either side of the normal axis in pure backward dislocation, depend- 
ing on the conditions outlined above. (See Outward and Inward 
Lateral Dislocation.) 

Complications. — ^Bone complications, particularly fracture, involve 
the humeral condyles and the tip of the olecranon, which is mashed 
by the force delivered from the humerus above or is pulled out by 




Fig. 318. — Backward dislocation of the 
elbow with epiphyseal separation and frac- 
ture of the internal condyle of the humerus. 



Fig. 319. — Backward dislocation of 
the elbow with epiphyseal separation 
of the olecranon. 



the attached ligament, the periosteum stripping off the bone surface 
(Figs. 318 and 319). The coronoid of the ulna may be cracked or 
split off completely, generally with little displacement. Frequently 
injury of the radial head is found. It may be cracked longitudinally 
or a chip may be broken off its inner side as the bone is displaced. 
Extreme violence acting before dislocation is complete may break 
the neck of the radius and the ulna near its upper end (Fig. 320). 
Rarely the lower end of the humerus is driven through the soft parts 
of the front of the elbow, or the brachial artery is ruptured. I have 
seen one case of closed elbow dislocation with arterial damage which 
led to gangrene and amputation. Reducible cases seldom lead to 



492 



DISLOCATIONS OF THE ELBOW 



involvement of nerves. The ulnar is spared unless there is condylar 
fracture. Dislocation of the ulnar nerve from its bed may accompany 
the elbow luxation and be independent of fracture of the internal 
condyle. Cobb^ found 2 cases in nine years at the Massachusetts 
General Hospital. There are now on record 23 cases which have 
been operated on after dislocation of this nerve, the only indication 
being pain and paralytic symptoms, the nerve dislocation itself not 
constituting any reason for open operation. The median and radial 
may be involved, especially in old irreduced dislocations which pro- 
duce much cicatricial tissue and callus formation beneath stripped-up 
periosteum. Open dislocations at the elbow are rare and usually 
accompany severe injuries and fractures of the same arm. 

General Symptoms and Signs of Dis- 
location of Both Bones at the Elbow. — 
In the backward and lateral disloca- 
tions the forearm is usually in a position 
of partial flexion, forming an angle ap- 
proximating 135 degrees with the arm. 
Rotation is impossible and when actively 
attempted is very painful. Looked at 
from in front the forearm seems short- 
ened, because the lower end of the 
humerus sticks forward, and bulging 
out the flexor muscles attached to the 
condyles broadens the forearm. A side 
or back view gives almost the opposite 
appearance, because the olecranon is 
raised above its normal level, the arm 
consequently seems shortened, and the 
forearm appears to have a normal 
length. There is thickening antero- 
posteriorly. The direction of the axis 
of the forearm may vary in or out 
within 15 degrees from the normal 
axis, and the hand may rest in any position from full pronation 
to extreme supination. The elbow- joint is enlarged, and if the 
patient is not seen until several hours after the accident the swelling 
may be great enough to obliterate all bony points. The forearm may 
be flexed a few degrees by passive motion, but never as far as a right 
angle and only with pain. The elbow has an abnormal lateral mobility, 
and when the forearm is flexed the olecranon may be seen to move 
beneath the skin on the back of the arm. There is muscle spasm and 
in some cases a pseudocrepitus caused by the rubbing of the forearm 
bones against the trochlear edge. Occasionally the forearm is in com- 
plete extension. 

Examination seeks to determine the position of the bony points 




Fig. 320. — Backward dislocation 
of the elbow with fracture of the 
lower end of the humerus. 



Ann. of Surg., xlviii, 409. 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 493 

previously mentioned. The points of the condyles and the olecranon 
are sought by palpation. The olecranon is found much higher than 
its normal level compared to the corresponding joint, with a depres- 
sion in the triceps tendon above it. The head of the radius may be 
seen or felt as a rounding projection behind the external condyle. 
This projection one can recognize at the head, or the head plus a 
portion of the broken-off external condyle, by pressing against it 
with the fingers of one hand while the other hand rotates the forearm. 
If it moves, it is probably the radial head; if it is immobile, it is cer- 
tainly the external condyle which has not been fractured. The internal 
epicondyle and ulnar nerve are also recognized by palpation. In 
front the surgeon may be able to identify the trochlear surface of the 
humerus by both sight and touch, not so easily in fat and muscular 
patients as in thin ones. 




Fig. 321. — Backward dislocation of the elbow and fracture of the radius. 

The diagnosis rests on the findings described and the lack of crepitus 
and shortening of the arm or forearm. To differentiate small fractures 
of the olecranon and radial head is difficult by whatever means of 
ex-ternal examination. Great tenderness over the radial head when 
the forearm is rotated may permit a diagnosis of fracture, particularly 
after reduction. However, one sees many cases overlooked and many 
diagnosed which are unproved by the roentgenogram. For that reason 
roentgenograms in both planes should be taken both before and after 
reduction of elbow dislocations, because bone injury of the coronoid 
and radial head may not appear in the first set of pictures (Fig. 321). 

I find it almost impossible to diagnose accompanying injury of the 
condyles without the help of the roentgenogram, and it seems that 
fractures of them are less common than tearing fractures of the ole- 
cranon, stripping of the humeral periosteum, and injury to the radial 
head. In children the differentiation lies between fracture just above 



494 DISLOCATIONS OF THE ELBOW 

the joint (dicondylar) and backward dislocation. In fracture the 
bony points maintain normal relation, and the deformity exists above 
the joint. T-fractures into the joint in adults are also difficult to 
differentiate, unless the loosened condyles can be grasped and manipu- 
lated independently to obtain crepitus and also motion. 

Prognosis. — ^The prognosis of fresh dislocations promptly reduced 
is good, unless there has been serious vascular or nerve injury. These 
complications are rare. Pressure on the radial or median, which 
gives numbness or tingling hyperesthesias, usually improves promptly 
after reduction. Fracture complications or the formation of callus 
beneath stripped periosteum may hinder the development of func- 
tional activity. After-treatment has much to do with functional 
return. 

The elbow- joint has a great tendency to produce irregular masses 
of callus not only connected with its bony points but also in the 
surrounding muscle. The brachialis anticus and the triceps are the 
usual muscles involved in a post-traumatic myositis ossificans. Pre- 
vious reference to this condition has been made in the chapter on 
the Pathology of Fracture. The origin of new bone formation is not 
always to be traced to periosteum. It may be a metaplasia of the 
connective tissue of the capsule or the intermuscular septa or may 
originate from osteoblastic cells which have wandered from the torn 
periosteum and proliferated. Lehmann^ collected 37 cases of post- 
traumatic ossification at the elbow-joint occurring in a period of eight 
years. Posterior dislocation had occurred in 19 cases. All showed 
new bone formation in the two muscles mentioned, part of it being 
of intramuscular formation. Complete rest for at least two weeks 
after reduction of dislocation has the greatest influence in reducing 
this par- and periosteal callus. We also know that in accordance 
with Wolff's law these masses slowly absorb and disappear, if irritation 
is not continued. Consequently a long immobilization of the arm in 
a flexed position will often cause their disappearance. Operative 
removal should be the last step in treatment after conservative methods 
have failed. 

When a luxation remains unreduced because of non-recognition or 
obstacles to reduction, it becomes impossible to effect reduction after 
a period of from four to six weeks on account of the cicatricial and 
callus changes which develop about the trochlear and sigmoid surfaces 
and beneath the stripped periosteum. (See Old Elbow Dislocations.) 
If the patient has a tendency to osteo-arthritis the surgeon may 
expect arthritic changes which tend to limit the joint movement, 
and they must be guarded against by a sufficient period of immobiliza- 
tion after reduction. Myositis ossificans involving the brachialis 
anticus and other muscles may follow after reduction of elbow dis- 
locations from the active proliferation of osteoblastic cells which 
have wandered into the muscles from torn periosteum. 

1 Deutsch. Ztschr. f. Chir., 1914, cxxvi, 213. 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 495 

Treatment. — Reduction must be accomplished as soon as diagnosis 
is made and can be done in several ways. Direct traction downward 
on the forearm in the direction in which it lies, with counter extension 
on the arm above made by an assistant, is the easiest method. When 
the traction separates the joint surfaces and unlocks the coronoid, 
if it is caught behind the trochlea, the forearm is brought into flexion 
as the traction is maintained by swinging it forward, and reduction 
follows. This method, with or without general anesthesia, succeeds 
in practically every fresh posterior luxation, regardless of the muscular 
development, and avoids much additional laceration of the ligaments. 
Most elbow dislocations have caused a great amount of tearing of 
the anterior and lateral ligaments, so that the greatest obstacle to 
reduction is the spasm of the muscles crossing the joint. 

Other methods are used successfully, a favorite one employed on 
young children consisting of direct pressure downward of the surgeon's 
thumbs against the displaced olecranon, while the hands grasp the 
arm above the joint and furnish counter-extension. The displacement 
is thus corrected by pushing. The surgeon may place his knee against 
the luxated elbow and by using it as a fulcrum and pulling the wrist 
down and around into flexion may cause easy reduction. He may 
also use for this purpose a solid mass like a bed post, bending the fore- 
arm around it. These* methods are open to objection, because, since 
considerable force is used to drag the forearm bones into position, the 
olecranon may be broken off by muscle pull, or the coronoid, or troch- 
lear surface may be injured by direct bony pressure. The capsular 
and lateral ligaments may also be torn more widely than they have 
been by the causative trauma. When the joint is very mobile and the 
ligaments are widely torn, reduction is easily accomplished by the 
attendant grasping the arm in one hand just above the elbow and 
making traction downward and forward on the wrist with the other 
hand, swinging the forearm up into place by flexion. With marked 
displacement backward and upward, when the coronoid is thoroughly 
engaged behind the trochlea, some hyperextension may be necessary. 
The forearm is bent backward into hyperextension, the humerus is 
pushed forward slightly just above the elbow by an assistant until 
the bone unlocks, and reduction is finished by downward traction and 
subsequent flexion of the forearm to swing the coronoid up around 
the trochlea. Complications caused by fracture of the condyles, of 
the olecranon, and of the radial head are not considered primary 
indication for operative treatment, unless reduction by manipulation 
and moderate force under anesthesia cannot be accomplished. I 
believe the best course is to obtain a reduction even if any of these 
fractures are present. The joint capsule and ligaments are then 
permitted to heal usually with the arm in flexion, and very often the 
fracture will also heal and cause little distur})ance. When the acute 
result of the dislocation has subsided and it is found })y examination 
that callus or a misplaced bone fragment interferes with function, 
open operation shoukl be performed^ for removal of the offending 



496 DISLOCATIONS OF THE ELBOW 

osseous fragment, the least possible amount of damage and opening 
being done. PVacture of the olecranon can be cared for by strapping 
of the upper fragment after reduction of the luxation, or by extra- 
articular wiring or nailing. Fracture of the head of the radius needs 
a long immobilization in a fully flexed position with subsequent 
excision, if there is interference with joint motion or pressure on the 
radial nerve. Operative treatment by arthrotomy is reserved for the 
rare irreducible fresh cases, the cases complicated by nerve, blood- 
vessel, and bone injury, and for the old unreduced cases. 

After-treatment in an ordinary case consists in retention of the 
forearm in a moulded splint in a position of about 60 degrees flexion 
for two or three weeks, or until passive motion in the direction of 
extension is painless, painlessness being an indication of complete 
healing of the ruptured capsule. After three weeks the arm is given 
light passive movements, is massaged freely, and is left out of the 
splint in a sling. Each day the sling is lowered, active movements 
short of pain production are encouraged, and function gradually 
returns in full. Patients possessing a tendency to a proliferative 
osteoarthritis are not hurried in after-treatment. The joint is never 
moved to a painful point, and although slight changes in the dressing 
may be made every day, the convalescence is prolonged to avoid 
painful joint irritation. 

Old Elbow Dislocations. — ^This subdivision really includes only 
those cases of luxation which have remained unreduced for some 
weeks until the secondary changes about the joint preclude reduction 
by ordinary manipulative measures. Because the operative technic 
is similar, the steps of arthrotomy for this condition must be used to 
cover partial or complete ankyloses which follow reduced dislocations. 
Parosteal bone growths, small fractures, or synovial ankyloses which 
indicate complete arthroplasty or bone resection may be present. 

Most old elbow dislocations are of the posterior variety. They 
may also be partly external or internal, a matter of little importance 
compared to the stiff position of the arm in extension. A few degrees 
of flexion may be possible, but the arm cannot be actively placed in a 
functionating position, the forearm cannot be rotated, and all move- 
ments must come from the shoulder. The patient is unable to bring 
the hand to the face or head for any purpose and the awkward posi- 
tion of extension is embarrassing. (See photograph of case. Fig. 322.) 
Reduction by manipulation and traction have been accomplished 
after many weeks, but there is great danger of fracture of the bone 
points and also of subsequent complete ankylosis when the forearm 
is finally brought into the desired position. Mr. Robert Jones has 
advised for old supracondylar fractures of the humerus or old posterior 
dislocations, when the arm is in the position of an obtuse angle with 
not more than 20 degrees movement, forcible flexion of the forearm 
under anesthesia. Repeated attempts are often needed. At first a 
few degrees of flexion are gained and held by a bandage. In a few days 
the patient is again anesthetized and a few more degrees of flexion 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 497 

are added, until finally complete flexion is obtained. The arm is left 
bandaged in that position for at least two weeks, after which active 
and passive motion toward extension are urged, and a good range of 
movement often results. The great danger of the forcible flexion is 
fracture. 

Pathology. — When an old unreduced elbow dislocation is exposed, 
the siu-geon is not surprised that reduction had not been possible by 
manipulation and traction. Roentgenograms taken in both an antero- 
posterior and a lateral plane will be guides in the planning of the 
operation, as far as the pathology is shown by bone shadow. Between 
the displaced olecranon, the sigmoid fossa, and the humerus, strong 
cicatricial bands have formed which prohibit flexion (Figs. 323 and 324). 




Fig. 322. — Old Ijuokward dislocation of the elbow ankylosed in complete extension. 



Callus has been deposited in the olecranon and coronoid fossae, about the 
olecranon, wherever the periosteum has been torn, and in the surround- 
ing muscles. The brachialis anticus and triceps are likely to be invaded. 
The greater sigmoid cavity is also filled with a mass of cicatricial tissue, 
so that if the bones could be pulled back into position on the trochlear 
surface the cavity would no longer fit them. Children who have 
actively osteogenetic tissues show greater callus formation in unreduced 
dislocation. On the anterior aspect of the joint the capsular tear 
generally leaves a curtain of fibrous tissue, which hangs down over 
the trochlea and seeks new attachment to the forearm bones. The 
torn lateral ligaments have healed in a cicatricial mass adherent to 
both the humerus and the forearm bones, and they form a firm obstacle 
32 



498 



DISLOCATIONS OF THE ELBOW 



to reduction. The nerves crossing the joint may be compressed in 
the contracted connective tissue. 

Bone injury is common. Tubby^ reported a case of postero-external 
dislocation of the elbow of six weeks' standing. Supination was 
reduced to 50 per cent., and the internal epicondyle of the humerus 
was fractured and enlarged by callus formation (Fig. 325). A similar 
case operated on by Henderson^ showed an excessive growth of bone 
about the lower end of the humerus, with fracture of the internal 
condyle. I have operated on four old dislocations in the last year, 
one with fracture of the radial head, one of the external condyle, and 





Fig. 323. — Old unreduced back- 
ward dislocation. Note the callus 
developed under the stripped 
periosteum. 



Fig. 324. — Reduced backward dislocation 
followed by ankylosis at a right angle. Note 
the callus in the olecranon fossa. 



two of the internal condyle. Hodge^ found an old postero-external 
dislocation with a crack an inch long and a loose piece of the 
external condyle. Donati^ found a fracture of the external con- 
dyle in an old posterior elbow dislocation and states that condylar 
fracture is present in 55 per cent, of all cases. Pibram, at the Surgical 
Congress in Paris, October, 1913, reported 16 cases from von Eisels- 

1 Proc. Roy. Soc. Med., London, 1913-14, vii, Surg. Sect., p. 157. 

2 Med. Press and Circ, London, 1915, N. S. xcix, 317. 

3 Ann. of Surg., Iv, 777. 

4 Arch, di Ort. 12 Maggio, 1912. 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 499 



berg's clinic in Vienna, and WalzeP later brought the total of the 
cases from this clinic to 19. Of their 19 cases there were 6 in which 
physical examination and roentgenogram failed to reveal any fracture 
or bone tearing, yet at the operation on these cases callus masses were 
found produced by torn periosteum or splinters of bone. These masses 
existed between the olecranon and the humerus, or in front between 
the coronoid and the humerus, and filled the olecranon fossa or bound 
the radial head. They also noted the great thickening and restricting 
presence of the torn anterior capsule. In 13 of the 19 cases some bone 
injury was discovered. Both bones of the forearm showed injury 
on the joint surface in 4 cases, the internal 
condyle was broken in 5, the radial head 
was damaged in 1, and in 2 the olecranon was 
fractured so that small fragments lay in the 
coronoid and olecranon fossae and in the 
incisura semilunaris. In most of these in- 
stances the fragments had healed on by 
callus, so that full joint excursion was im- 
possible. 

The 6 cases uncomplicated by fracture 
reported by Walzel showed full ankylosis in 
3, flexion limited to 120 degrees in 2, and 
to 160 degrees in 1. Of the 13 cases grouped 
together on account of bone lesions, 5 were 
completely ankylosed, 2 allowed a passive 
motion of 60 degrees, and 5 a motion of 
from 10 to 30 degrees. One can plainly 
understand that forcible flexion and manip- 
ulation are quite unavailing for reduction, 
and are likely to lead to further fracture 
without satisfactory reduction when much 
force is applied. 

Operative Treatment. — Open operation for 
old elbow dislocations may be divided into 
( 1) arthrotomy with (a) simple replacement, 
or (h) arthroplasty. 

(2) Resection of the whole end of the humerus 
with or without the use of arthroplastic flaps. 

f3j Atypical resection of loose bone bodies, masses of callus or the 
radial head. 

The surgeon ofi'ers the patient the opportunity of bettered position 
of the forearm and of relief from nerve pressure, even if a subsequent 
ankylosis occurs. With the arm in a more useful position, the deform- 
ity is not so noticeable, and function is proportionately improved. 
The patient incurs the risk of ankylosis, infection, and possibly later 
amputation in a very small percentage of cases, but we have learned 




Fig. 325. — Old postero- 
lateral dislocation with callus 
development. Irreducible 

by manipulation. 



• Verhandl. d. deutsch. Gesellsch. f. Chir. 
kUn. Chir., Bd. cv, 1 Heft, 2. 



Berlin, 1914, xliii, 2 Theil. p. 120; Arch. f. 



500 DISLOCATIONS OF THE ELBOW 

that arthrotomy is not dangerous and can become a routine operation 
in the hands of those trained for it. Nicoladoni^ reported 11 cases of 
arthrotomy for old dislocations, 2 of which were of the elbow, and 
both gave fair results. Lexer, Murphy, Bunge, and Dollinger have 
proved this possibility of result. In 1908 at the German Surgical 
Congress Bunge collected 42 cases of arthrotomy at the elbow. Bunge 
had performed 17 cases of bloody reposition of elbow dislocations in 
thirteen years at the Konigsberg clinic. Those performed through a 
bilateral incision at the joint gave a ratio of 50 per cent, good results, 
while those with a unilateral incision showed but 25 per cent, good 
results. Dollinger^ reported 45 cases of old traumatic dislocation of 
the shoulder, hip, and elbow. Of these 28 were subjected to arthrot- 
omy, and he concluded that resection of joints should only be made 
as a last resort when it was found that arthrotomy offered no hope 
of a functionating joint. Bockenheimer^ advocated arthrotomy with 
the strictest asepsis and a minimum time of exposure of the joint 
structures. 

The pathological changes about the joint are such that operation 
alone offers hope of betterment of the deformity. 

Operative Technic. — ^The incision may be bilateral or unilateral, 
depending on the operator's choice, the lateral character of the dis- 
location, and the knowledge gained from the roentgenogram. The 
various single incisions are down the back of the humerus slightly to 
one side of the projecting olecranon, down the external aspect of the 
joint over the external condyle, or along the inner aspect of the joint 
just above the level of the ulnar nerve. Double incisions can be 
made, one on either side of the olecranon about one and a half inches 
apart, first advised by Murphy for arthroplasty, or one over the 
inner and over the outer condyle of the humerus nearer the anterior 
surface. In Walzel's 19 cases the following approaches were made: 
6 outer incisions, 1 inner, 2 posterior, and 10 bilateral. After trying 
the double incision I have finally come to using an incision 8 inches 
long over the inner aspect of the joint above the path of the ulnar 
nerve. The nerve is first isolated by being lifted from its bony bed 
and held retracted out of the way. Complete excision of fibrous tissue 
and healed capsule is then begun, the operator clinging closely to the 
bone surfaces. A wide dissection is necessary, and all callus and cica- 
tricial masses must be removed by sharp tools. I find small curved 
artists' chisels are especially adapted to cleaning out the olecranon 
and coronoid fossae, and the capsule, lateral ligaments, and triceps 
tendon are not spared in dissecting efforts directed toward freeing the 
bones. Every part of the joint should be fully exposed to view and be 
made movable. By hugging close to the bone surface in reflecting 
the obstinately adhering anterior portion of the capsule, the surgeon 



1 Wien. med. Wchnschr., 1885, No. 23. 

2 Ergebn. d. Chir. u. Orthop., Bd. iii, 83. 

3 Munch, med. Wchnschr., 1911, Iviii, 2560. 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 501 

avoids bloodvessels and nerves. The bones may be bent out of the 
soft tissues to permit a thorough cleansino- of the adherent scar tissue. 
Generally a reduction can be accomplished after such a thorough 
exposure, and the capsular and ligamentous tags can be sutured 
together over the joint. If bony parts still obstruct reduction, I 
belie\e it is better to deepen the greater sigmoid cavity, to shorten 
the tip of the olecranon, or resect the head of the radius before resecting 
the lower end of the humerus. If there is much bare bone, or any 
fear of subsequent ankylosis, a flap of fatty tissue is dissected up from 
the anterior surface of the soft parts about the elbow and is swung 
down, attached by a pedicle, between the bone surfaces. In one 
case I found this flap was necessary, and although reduction could 
be made with all bones intact, I was compelled to resect the radial 
head to avoid destructive pressure on the fat flap when the arm was 
brought into flexion. The operation is preferably done without a 
constrictor, because it requires from one and a half to two hours to 
complete and because hemostasis is an essential part. With the con- 
strictor it is impossible to avoid considerable oozing after the wound 
is closed, and the hematoma which forms interferes with the result 
and leads to infection. The subcutaneous tissues are closed by inter- 
rupted catgut sutures — a continuous suture may pull out entirely — 
and the skin is completely closed by silkworm gut or clips, in spite 
of any tension which may exist. Many cases develop stitch-point 
infections, or the superficial skin sloughs in small areas, but as long 
as the infection does not penetrate into the new joint no fear of 
unsatisfactory result need be entertained. 

The arm is dressed in about 60 degrees flexion in a firm moulded 
splint of plaster and is kept immovable for about a week, unless the 
dressings become saturated and require removal. Once I had quite 
extensive skin sloughing from pressure and once stitch abscesses in 
the superficial tissues. All cases healed without deep infection. The 
19 cases of elbow arthrotomy reported by Walzel resulted in primary 
union in 13. There were 4 cases of afebrile hematoma, 2 of some 
secretion with fever, and 1 requiring incision for drainage. Of his 
10 cases treated by bilateral incision only 1 showed infection and fever, 
and that gave a good result. When a case becomes infected after 
operation, it should be afforded sufficient drainage and be held immob- 
ilized at a suitable angle of flexion of the forearm. 

The after-treatment consists of daily light passive movements 
without pain in the second week, the arm being dressed in a light 
moulded splint. In the third week the splint can be dispensed with, 
the patient is encouraged to make active movements, and after the 
fourth week all possible active use of the hand is necessary. The 
results are generally quite satisfactory to the patient. The forearm 
is in a useful position — a woman can get her hand to her face and hair, 
and all patients can use the hand for eating and other functions. The 
amount of flexion and extension possible varies. I have had results 
from 80 to 120 degrees of motion in the elbow-joint. The joint 



502 DISLOCATIONS OF THE ELBOW 

gradually becomes stronger and will support much weight. Hodge^ 
obtained 75 degrees motion in his case after one month. Tubby 
obtained active motions of 90 degrees after three weeks. Seventeen of 
Walzel's 19 cases were traced for results. Three resulted in ankylosis, 
with better position, 7 had a practically normal joint, 7 had a good func- 
tionating joint with a minimum excursion angle of 80 degrees and a 
maximum of 100 degrees. Out of the 19 reductions by arthrotomy 15 
useful extremities w^re obtained. 

Lateral Dislocations of Both Bones of the Forearm. — (a) Outward 
dislocations, (b) Inward dislocations. Lateral dislocations of both 
bones may be outward or inward from their normal longitudinal axis, 
but the term true lateral dislocations implies that the articulating 
surfaces of the forearm bones remain in their relative position to the 
transverse axis of the lower end of the humerus. This means that 
there is no posterior or anterior displacement and that the coronoid 
lies in front of and the olecranon behind the axis of the trochlear sur- 
face of the humerus. Lateral displacements may be complete or incom- 
plete; both bones may be widely displaced free from the end of the 
humerus, or one bone may still lie in contact with the trochlear or 
condylar surface. 

(a) Outward Dislocations. — Outward dislocations are the commonest 
variety of lateral displacement, and they are divided into three 
varieties : 

(1) Complete outward dislocation with pronation of the forearm. 

(2) Complete without pronation of the forearm; a very rare kind. 

(3) Incomplete outward dislocation. 

1. Complete outward dislocations with pronation of the forearm 
have been recognized more than a hundred years, and yet there are 
not more than 35 cases on record. The causes are not well under- 
stood but may be falls on the pronated forearm or elbow or direct 
violence on the inner side of the forearm. One case which I have seen 
was caused when the patient's forearm was caught in a swiftly moving, 
broad-power belt, and sustained a violent wrench from within outward, 
while his arm was at right angles to the long axis of the belt. The 
forearm is slightly flexed and is pronated, the sigmoid surface of the 
ulna being turned inward by rotation on its long axis. 

2. In complete outward dislocation without pronation both bones 
are carried laterally displaced outside of the lower end of the humerus 

*and yet not pronated. This form is exceedingly rare. 

3. Incomplete outward dislocation is probably not so rare. The 
sigmoid cavity of the ulna has not passed completely outside o| the 
trochlea, or at the most has come to lie against the external condyle, 
the coronoid still being in front of the humerus (Fig. 326). 

Pathology. — In the first type with rotation both the lateral and the 
anterior ligaments must be widely lacerated. The forearm is pronated 
and flexed so that the head of the radius lies on a higher level than the 

1 Loc. cit. 



BACKWARD DISLOCaTIOX OF BOTH FOREARM BONES 



m 



sigmoid of the ulna, which Hes turned inward, resting against the 
outer surface of the external condyle of the humerus. The radial 
head may lie slightly inward from the ulna, and the orbicular ligament 
is not often destroyed. The ulnar and radial nerves may be injured 
by pressure or laceration. The epitrochlea may be broken off, as 
reported by Stimson and Heuter,^ and become an obstacle to reduc- 
tion. In the second class the forearm bones are carried completely 
outside of the end of the humerus and are not rotated, so that the 
inner edge of the sigmoid of the ulna, which looks forward as normally, 
lies against the outer side of the external condyle, the coronoid in 
front and the olecranon behind. In either of these forms the muscles 
attached to the epitrochlea may 
be completely torn oft'; theoreti- 
cally they still, in the pronated 
variety, retain their attachment, 
and by their action have caused 
the rotation of the luna. 

In the third type, the incom- 
plete outward dislocation, the 
lateral ligaments must be more 
or less completely ruptured and 
the anterior ligament also torn 
away. The radius is displaced 
outward and probably a little for- 
ward, retaining its attachment to 
the ulna. The sigmoid cavity of 
the ulna has moved outward part 
of the way, so that it comes to lie 
against the outer lip of the troch- 
lea or against the capitellum. The 
epitrochlea may be broken off 
and displaced up into the troch- 
lea to obstruct reduction, as in 
the complete lateral dislocations. 
Xicoladoni's experiments on the 
cadaver seemed to prove that the 
epitrochlea was torn off' by the avulsion of the attached group of 
forearm flexors rather than by the tearing out of the capsular liga- 
ment, which is inserted at its extreme lower edge only. 

Symptoms- and Diagnosis. — In all forms of outward dislocation the 
elbow is slightly flexed and it is broadened, thus exhibiting a distinc- 
tion from backward luxations. Usually also the forearm is pronated; 
it is extremely so in the forms with pronation. The long axis of the 
forearm may be parallel with the arm but lies outside. There is some 
motion present, sometimes an astonishing amount, because there is 
no bony interference with flexion, and more flexion is permitted than 




Fig. 326. — Incomplete outward disloca- 
tion with fracture of the condyle. The 
bone fragment was not an obstacle to re- 
duction, but the piece above had to be 
removed. 



Stim.son, Fractures and Dislocations, 7th edit., p. 098. 



504 DISLOCATIONS OF THE ELBOW 

in posterior dislocation. Rotation is limited. Examination of the 
elbow shows the iniduly prominent internal condyle, with the skin 
stretched tightly over it. The transverse measurement at the elbow 
may be doubled. Palpation reveals the sharp edge of the internal 
condyle and epitrochlea, and in complete outward dislocation the 
rounded surface of the trochlea may be felt. Posteriorly the olecranon 
can be felt displaced outward, and the head of the radius lies either 
anterior or lateral and is very prominent. The triceps tendon can be 
seen and felt, extending to the outward displaced olecranon. When 
the forearm is pronated in complete luxation, the olecranon points 
directly outward, the sigmoid fossa is turned in against the external 
condyle of the humerus, and the radial head becomes the most palpable 
mass just in front of and outside of the external condyle. The extensor 
muscles form a bulging mass on the anterior surface of the elbow. 

Treatment. — Reduction is not difficult in fresh outward dislocations, 
unless the epitrochlea has been broken off and lies on the trochlea to 
prevent the ulnar sigmoid from fitting over it. In the forms of complete 
luxation the forearm is extended with traction, and the ulna and 
radius are pressed inward and over into position as the forearm is 
brought into flexion. This manipulation does not require great force, 
because the ligaments have been so widely torn that the bones are 
mobile and slip over each other easily. If the forearm is in pronation, 
as the reduction is accomplished by traction and pressure, the hand 
is swung around into supination to bring the ulnar sigmoid into normal 
relation with the trochlea, the head of the radius being turned to the 
outside of the joint and pushed under the capitellum. 

In the incomplete type the surgeon wishes to lift the ulnar sigmoid 
from its position outward between the trochlea and capitellum over 
onto the trochlea. This proceeding may be accomplished by extension 
of the forearm with traction while an assistant pushes the forearm 
bones inward into place. If this movement fails, one may obtain 
reduction by making some abduction to free the ulna from its locked 
position against the humerus. Slight abduction is of assistance if 
the radial head still lies partly beneath the external condyle, because 
that point is used as a fulcrum for the leverage. After the ulna is 
freed the forearm bones may be pushed over into place. If the orbicular 
ligament which holds the radial head to the ulna is ruptured, this 
lever will not be efficacious, and the olecranon must be pressed upon, 
that it may be moved over into place. 

Incomplete outward dislocations have frequently been complicated 
by fracture and displacement of the epitrochlea onto the trochlea and 
this small mass of bone becomes a great embarrassment in reduction. 
Partial reduction may be accomplished with this bit of bone lying 
between the humerus and ulnar sigmoid, but joint motion is not free, 
and there is usually some persisting abduction of the forearm. The 
fragment may be squeezed out of the joint and into position on the 
inner side of the arm by lateral flexion of the forearm, which is bent to 
a right angle. This endangers the skin on the inner aspect of the 



BACKWARD DISLOCATIOX OF BOTH FOREARM BONES 505 

joint. It may be punctured, or the ulnar nerve may be stretched. 
Open operation for the remo\'al of the foreign piece of bone by an 
approach on the inner side of the joint is the treatment of choice. 

Inward Dislocations. — Inward dislocations are never complete in 
type. The ulnar sigmoid lies in part contact with the trochlea, and 
the radial head may not move from the capitellum, so that the dis- 
location may really be one of the ulna inward alone. However, the 
head of the radius usually lies within the capitellum against the ridge 
of the trochlea, and it forms there a new articulating facet. The 
lateral ligaments are torn and the anterior ligament may be merely 
stretched and not lacerated. If the radial head remains in normal 
position, the orbicular ligament must be torn. It may lie in front of 
or even behind the end of the humerus. 

Symjjfovis and Diagnosu. — The forearm seems shifted inward, its 
axis corresponding with that of the humerus. The internal condyle 
of the elbow is less prominent than the opposite joint, the olecranon 
fossa is empty to palpation, and the olecranon can be felt inside of 
this space riding over the epitrochlea with a corresponding deviation 
of the triceps tendon. The external condyle may become prominent, 
and the radial head is lacking below but is found back of the humerus 
in most cases. Motion in the joint is free because of ligamentous 
tearing, unless there is a large hemarthrosis. 

Treatment. — Reduction is easily accomplished by traction and 
extension of the forearm aided by pressure against the olecranon or 
upper end of the ulna outward. If this manipulation fails, the forearm 
may be abducted during the traction, whereupon the lateral pressure 
pushes the ulna into place. 

Prognosis and results of lateral dislocations are good. There is 
little tendency to recurrence, if the arm is immobilized in a light 
plaster splint for a week. Function rapidly returns, and ultimate 
results are satisfactory, with some limitation of joint motion after 
the ligaments have healed and cicatrized. When the luxation is not 
reduced, function may become quite serviceable, although motions 
are restricted. This statement is truer of incomplete than of complete 
dislocations, which are subjected to the traction of unbalanced muscles 
or which are greatly limited in motion by the position of pronation. 
Efi'ort should be made to reduce fresh dislocation at once; old cases 
can be treated in accordance with the outlines of treatment laid down 
for old posterior dislocations, each case becoming a problem for the 
surgeon to solve on its own findings. Resection should be the last 
step and arthrotomy the usual operation. 

Dislocation of Both Forearm Bones Forward. — Forward dislocation 
of both bones at the elbow is extremely rare and may be accompanied 
by fracture of the olecranon, the proximal fragment of which, with 
the triceps attachment, remains in situ. When the fracture is so 
important to the displacement forward, the case should not be con- 
sidered a true dislocation. Both bones may be displaced anteriorly, 
so that the posterior surface of the olecranon lies against the anterior 



506 DISLOCATIONS OF THE ELBOW 

surface of the trochlea, or in a less complete form the tip of the ole- 
cranon lies against the trochlea without displacement up onto its 
anterior surface. 

The causes in the reported cases have varied from falls on the palm 
and flexed forearm to violent twisting strains which involve the 
hand and forearm. Canton^ reported a case in which the patient, an 
adult male, was thrown from his wagon and struck on his extended 
hand, the forearm immediately crumpling beneath his chest. Stauton^ 
records an instance in which the patient sustained a fall on the flexed 
elbow. The anterior dislocation may result from torsion or pronation 
stress exerted on outward lateral dislocations, so that the forearm 
bones are pulled over in front of the elbow-joint. 

Pathology. — The lateral, the anterior and the posterior ligaments 
must be torn to allow for the displacement. In the complete form, 
when the upper ends of the forearm bones ride up onto the anterior 
humeral surface, the triceps tendon must be torn from its insertion. 
This was so in Canton's case. The luxation may become open by 
the projection of the humerus through the tense skin on the back of 
the joint, or by the forearm bones thrusting a way through the tissues 
on the anterior surface. The orbicular ligament and the upper part 
of the interosseous ligament may be torn. In the forward displace- 
ment the flexor gfoup of muscles attached to the lower end of the 
humerus are torn off, and the ulnar nerve may be also torn apart. 
Fracture of the olecranon permits an easy dislocation forward, if the 
ligaments are severed, and this condition really belongs in the fracture 
group. Concomitant fractures of the epitrochlea and the condyles 
are contained in the reported cases. Lambert^ did an open operation 
on a forward dislocation. The orbicular ligament was unruptured, 
the triceps were only partly detached from the olecranon, and the 
internal epicondyle which had been detached from the humerus was 
found displaced with the ulna and attached to the coronoid. Bone 
fragments were removed and a replacement made with a happy result. 

Symptoms. — In the complete variety the limb must be in extension, 
usually 120 to 140 degrees, and some flexion, even to a right angle, 
may be possible passively. The flexed forearm is lengthened slightly 
when the olecranon is not broken, but in extension there is shortening. 
The most striking finding is that the forearm can be hyper extended, 
with no great pain, and as this action is performed the head of the 
radius and the coronoid of the ulna can be felt beneath the tissues in 
the anterior fold of the elbow. The olecranon is missing on the pos- 
terior aspect of the joint, the fossa is empty and palpable, and the 
joint is thickened anteroposteriorly, not laterally. In the incomplete 
form the tip of the olecranon is held against the trochlea by the tense 
triceps tendon, which still retains its attachment, and the forearm is 
in flexion. The olecranon sticks out prominently below the end of 
the humerus, and the forearm is lengthened in extension. 

» Dublin Med. Jour., 1860, ii, 24. 2 Brit. Med. Jour., 1905, ii, 1520. 

3 Ann. of Surg., iiii, 866. 



BACKWARD DISLOCATION OF BOTH FOREARM BONES 507 

Treatment. — Reduction has been accomplished in every case except 
Canton's which remained unrecognized and unreduced for several 
weeks and in which supracondylar amputation was finally performed. 
For reduction the forearm is flexed, traction is made on it, and the 
forearm bones are pushed out away from the humerus at their upper 
end to permit the olecranon to slide back into place. The operator's 
knee may be placed in the anterior elbow fold to act as a fulcrum for 
this leverage. Complete dislocation with the forearm bones riding 
high on the humeral surface must be converted into the incomplete 
type by flexion and traction and the olecranon then shoved down into 
place. The subsequent course and prognosis depend on the presence 
or absence of open wounds about the joint, laceration of muscles and 
ligaments, and infection. Ten to fourteen days' immobilization is 
given the closed dislocation before any passive motion is started. 
Open or infected luxations are treated according to the general prin- 
ciples applied to open fractures and dislocations. 

Divergent Dislocation of the Forearm Bones. — In this rare type of 
forearm luxation the bones are dislocated simultaneously but do not 
accompany each other, that is, they spread apart to permit the lower 
end of the humerus to be shoved between them. There are conse- 
quently two types of divergent dislocation, depending on the position 
of the arm at the time of accident and the direction of the force. If 
the forearm is completely pronated and the force drives the forearm 
bones up onto the humerus, they can be displaced only after the 
lateral, anterior, and posterior ligaments of the elbow-joint are torn 
apart and the orbicular ligament and the interosseous membrane which 
hold the radius and ulna together have been bursted. A force powerful 
enough to accomplish this end and directed at the right angle is rare, 
and the ligaments practically never yield, the bone generally sufi^ering 
fracture. With the forearm pronated, the separated bones are dis- 
placed on the humerus, the radius on the anterior surface and the 
ulna on the posterior. That constitutes the most common form. The 
other form, of which only two cases are recorded in the literature, 
Guersant's^ and Wight's,^ is the transverse, in which the arm is probably 
supinated at the time of accident, and the ulna is driven up on the inner 
side, the radius up on the outer side of the humerus. Variations of 
these displacements have been described, probably caused by second- 
ary positions from continued trauma or muscular action. 

Symptoms and Diagnosis. — The forearm may assume any position 
of slight flexion to complete extension and rotation, and the elbow is 
thickened anteroposteriorly. On account of the swelling and shorten- 
ing of the forearm the condition may be mistaken for backward dis- 
location, or supracondylar fracture of the humerus. There is pain 
and no active movements, while passive movements of flexion and 
extension are limited. Bockenheimer^ reported an unreduced case 

' Warmont Rev. Med.-Chir., xvi, 303. 

2 Physic and Surg., Ann Arbor, February, 1893. 

3 Munch, med. Wchn.schr., 1911, Iviii, 2,560. 



508 



DISLOCATIONS OF THE ELBOW 



of divergent (lislocation in a twenty-year-old man. He had been 
knocked down, falling on his extended and pronated forearm, which 
remained fixed in extension after the accident. The displacement 
had lasted many weeks, and examination showed that the radial head 
was located on the flexor side and the olecranon on the extensor side 
of the humerus (Fig. 237). In the normal position for the radial head 
there was a vacancy, and the olecranon fossa was also empty. 

Treatment. — The forearm is manipulated in partial flexion with 
traction and counter-traction on the arm reducing the ulna much as 
in posterior dislocation. When that has been reduced, the forearm 




Fig. 327. 



-Divergent dislocation of the elbow, 
case. 



A drawing made from Bockenheimer's 



can be carefully extended and slightly adducted and the radial head 
pushed down into position by direct pressure. A fixed dressing in a 
position of about 120 degrees extension will probably prevent recur- 
rence, although the published cases give scant information as to results. 
Bockenheimer had to operate on his case, which was unreduced after 
he had tried reduction by manipulation under anesthesia. He made 
a 12 cm. incision over the radial extensor side of the joint and avoided 
all the nerves. The ulna was first reduced, and then it was found that 
the radius head would not remain in position unless the forearm was 
put in a position of extreme flexion. The torn capsule was united 
with catgut, and within eight days after operation there was primary 



DISLOCATION OF THE RADIUS ALONE 509 

union and the cast was remoAed. In three weeks active mo\ ements 
were started, and in two months there was full function in the elbow- 
joint, including pronation and supination. 

DISLOCATION OF THE RADIUS ALONE. 

1. Dislocation forward. 

2. Dislocation backward. 

3. Dislocation outward. 

Luxation of the head of the radius is found frequently with fracture 
of the shaft of the ulna high up. The ulnar fracture, which is obvious 
on account of the angularity in its continuity, may cause the surgeon 
to overlook the injury of the radius. Ever^^ ulnar shaft fracture 
should be scrutinized for possible luxation or subluxation of the head 
of the radius, and in elbow injuries with swelling, loss of supination, 
and limited extension the elbow-joint must be included in the roent- 
genogram. Likewise in all dislocations of the radial head the shaft 
of the ulna must be inspected for possible fracture. Stetten,^ reviewing 
this subject, found over 120 cases, about one-tenth of which were 
complicated by nerve injury. The exact mechanism of this double 
injm-y is not known. The radial head may be dislocated primarily, 
and the continuation of the force transmitted through the hand in 
falls may then break the ulna, because the strong interosseous fibers 
hold, and the radius retains its axial relation to the lower fragment 
of the ulna. Another possible explanation lies in primary ulnar frac- 
ture with a secondary rupture of the orbicular and other ligaments 
about the radial head, which permit its luxation when it acts as the 
sole transmitter of the violence to the forearm after the ulna has 
given way. 

The radial head may be displaced backward and press on the radial 
or posterior interosseous nerves. The larger part of the cases causing 
nerve injury in dislocations of the radial head are those combining 
radial dislocation and ulnar fracture. Carrey^ records a case of nerve 
injury from dislocation alone. Stetten's article, referred to previously, 
states that the case he reported of radial paralysis caused by ulnar 
fracture and radial head luxation was the ninth on record. Sherren^ 
knew of two instances. He performed some experiments on the cadaver 
to study this lesion and found on dissection that both the posterior 
interosseous and the radial nerve were twisted around the radial head 
in such a way that after reduction of the luxation they slipped off. 
When the joint was redislocated they caught again on the displaced 
raflial head and were considerably stretched. It was found impossible 
to rupture the nerves by hyperextension of the forearm. The integrity 
of these two branches of the musculospiral nerve is threatened in 
nearly every radial head luxation. \Yhen the head is displaced for- 
ward and outward one or both branches may be stretched. If the 

1 Ann. of Surg., xlviii, 275. 2 Th6se de Lyon, 1894. 

^ Injury to Nerves and Their Treatment, London, 1908. 



510 



DISLOCATIONS OF THE ELBOW 



luxation is forward and inward the nerves are usually not injured. 
A simple forward dislocation involves the radial nerve alone, a simple 
outward dislocation usually involves only the posterior interosseous, 
while in backward elbow dislocation neither nerve is likely to be 
injured. 

Fisk^ reported an unrecognized case of combined ulnar fracture and 
radial dislocation which was followed by Volkmann's ischemic con- 
tracture. He was able to find over 140 cases of the combined injury 
recorded. Five were operated on at once and 26 after an interval of 
several months. The ligaments about the head may prevent reduc- 
tion, and the fracture is difficult to maintain reduced, because the 

forearm must be held straight to 
correct the ulnar deformity, and the 
radial dislocation tends to recur 
unless the forearm is flexed to hold 
the head against the capitellum. 
Some surgeons consider this com- 
bination a primary indication for 
open operation, either to plate the 
ulna or to reattach and reinforce 
the ligaments at the radial head. 

Dislocation of the Radius For- 
ward. — ^This class is meant to in- 
clude the pure luxations, to the 
exclusion of those complicated by 
fracture of the ulna just described 
and of the peculiar type of sub- 
luxation of the radial head in 
children, which will be discussed 
in a separate paragraph. For- 
ward dislocation is the most com- 
mon of the radial luxations (Fig. 
328). The head is torn from its 
normal position and is shifted 
forward for a varying extent 
depending on the laceration of 
the ligaments, so that in extension of the forearm the head of the 
bone lies forward and when the forearm is flexed the head rises above 
the normal position, where it can be felt or seen in the shadow of the 
roentgenogram. 

Direct violence on the upper part of the forearm, falls on the hand, 
and extreme pronation of the forearm are the causes. If the orbicular 
ligament is lax, violent contraction of the biceps muscle may produce 
dislocation by traction exerted through the insertion of its tendon. 
In children the type of subluxation induced by pulls on the forearm, 
probably a little hyperextended is clearly understood, and in adults 




Fig. 328. 



-Dislocation forward of the 
radial head. 



» Ann. of Surg., Ivii, 266. 



DISLOCATIOX OF THE RADIUS ALONE 511 

it seems that abduction and possibly pronation are necessary to cause 
the head to be kixated. 

Pathology.— The author has operated on a fresh forward dislocation 
which could not be held in position. The orbicular ligament was torn 
off for three-quarters of its attachment, and the anterior ligament of 
the elbow had a rent in it through which the radial head half-protruded. 
The edge of the capitellum interfered with reduction until the forearm 
was hyperextended and the torn ligament was slit wider open. Reduc- 
tion was then accomplished. ^Nlany reported cases show that the 
orbicular ligament has remained intact, but the anterior joint capsule 
has been ruptured. In old cases the radial head lies forward and 
slightly inward on the capitellum. It may lie close to the coronoid 
process of the ulna and be surrounded by healed fragments of torn 
ligament which have bound it in the new position. Cracks in the 
head extending as far as an inch down into the neck, or a chipping off 
of small bone fragments, have been seen in operated cases. 

Symptoms and Diagnosis. — The forearm is in a position of partial 
flexion and usually pronated, so that there is some abduction when it 
is compared to the opposite limb. Flexion to a right angle can be 
accomplished, often without pain, but at that limit the joint is felt 
to lock and the forearm cannot be forced farther up. Extension may 
be complete. Examination of the elbow by rotation of the forearm 
discovers the radial head lacking from its normal position. It can be 
felt by one's tracing down the biceps tendon and lies inward and for- 
ward from the external condyle of the humerus. The lateral roentgeno- 
gram with the forearm extended shows the head of the bone riding 
upward. 

Treatment. — In most recent cases reduction is easy. The wrist is 
grasped and traction is made in slight adduction, while the forearm 
is slowly supinated and direct pressure is made by an assistant down 
on the head of the radius. The forearm is then gradually flexed, and 
the assumption of a position of full flexion verifies the fact of reduction. 
Recurrence, common after this luxation, can be avoided by maintain- 
ing the forearm flexed. The pull of the biceps tendon on the radius 
is thus relaxed, and the ligaments are given an opportunity to heal 
with the bone in its normal position. Some cases are irreducible by 
manipulation and are cured only by operation. Reduction attempts 
under anesthesia with a fulcrum or block in the anterior cubital fold 
should be tried before operation. A short incision is made over the 
radial head, the bone is freed from adhesions, the capsule is opened 
to receive it, and it is pressed and manipulated back into place. If 
the replacement cannot be eft'ected on account of new growth of bone 
and fracture of the head, and if full flexion cannot be attained after 
reduction, it is best to excise the head and hang a small flap of fascia 
over it to prevent bony outgro\^i:h. The cases complicated by nerve 
injury or ischemic contracture, or recent cases which cannot be reduced 
by manipulation, are treated by arthrotomy without fear of disturb- 
ance of joint development and function. I have resected several 



512 DISLOCATIONS OF THE ELBOW 

for interference with flexion of the forearm and one for nerve disturb- 
ance. Auzilotti^ reported 2 cases. Uffreduzzi^ collected 49 cases 
of congenital dislocation of the radial head, 5 of which were operated 
on. He also included 1 case of reduction of a recent dislocation by 
arthrotomy in a fourteen-year-old boy. 

Dislocation Backward. — Dislocation backward of the radius at the 
elbow is rare. The radius may not leave entirely its contact with 
the capitellum, or it may be displaced posteriorly upward and behind 
the external condyle. The degree of displacement, as in all luxations, 
probably depends on the amount of capsular and ligamentous tear 
and accompanying fracture. Cameron^ reported an instance in an 
elderly man who was caught between a wall and a cart and whose 
forearm was squeezed lengthwise with the hand in pronation. The 
\ iolence forced the radial head out behind the external condyle just 
under the skin, and the cavity on the top of the head could be pal- 
pated. Other cases have been caused by falls on the pronated hand 
with the forearm in part flexion, the force being transmitted up the 
long axis of the radius in a manner which caused the bone to be dis- 
placed backward. Experimentally it is almost impossible to reproduce 
this type of dislocation on the cadaver, probably because the exact 
mechanical cause is not known and the influence of actively contracting 
muscle groups is lost. 

No fresh cases have been examined; so the exact pathology is not 
known. Undoubtedly the orbicular ligament and joint capsule are 
torn, the edge of the external condyle may be sheared off, and the 
bone head lies behind the external condyle. The radius is also sepa- 
rated partly from the ulna, which remains in position. The diagnosis 
can be made on inspection when the head of the bone is found back 
of the external condyle and the hollow end is felt beneath the skin. 
The arm is usually flexed and pronated, and all movements at first 
are painful and restricted, but this limitation gradually subsides, and 
in old unreduced cases the function has been good with full motion 
in all directions except supination. 

Treatment. — Recent cases are reduced by traction on the wrist and 
adduction of the forearm aided by direct pressure forward and inward 
on the radial head. After reduction the hand is supinated and the 
forearm fixed in partial flexion to safeguard against recurrence. In 
twelve to fourteen days the ligaments have healed sufficiently to 
permit gentle passive motion. 

Unreduced cases demand operation, seldom to improve the function, 
but more often to overcome deformity. Stimson^ has recorded Lar- 
kin's case of overgrowth of the radial head after backward dislocation 
(Fig. 329), The radial head should be excised if reduction is impossible 
and functional or cosmetic reasons indicate. 

1 La Riforma Med., March 14, 1914, xxx. 

2 Arch, di Orthop, December, 1913, p. 658. 

3 Lancet, 1884, i, 885. 

'' Fractures and Dislocations, 7th edition, p. 723. 



DISLOCATION OF THE RADIUS ALONE 



513 



Dislocations Outward. — Outward dislocations are rare and are fre- 
quently accompanied by fracture of the ulna. The causes are direct 
pressure outward on the radius, while the forearm is fixed in flexion. 
Wagner^ reported 3 cases, all complicated by breaking off of part of 
the radial head. Lobker- reported 2 cases treated by excision. Shrot- 
ter^ had previously collected 26 cases, 3 of which were complicated 
by radial fracture. The movements in the elbow-joint are greatly 
restricted, the elbow may appear broadened because the radialhead 
Ues on the outer side of the capitellum, and the head either is fixed 




Fig. 



329. — Excessive growth in length of the radius after dislocation of its upper end 
in youth. (Stimson.) 



or can be felt to rotate in the new position. The orbicular ligament 
must be stretched or torn and probably the periosteal damage of the 
humerus and radius leads to a thickening by callus in the old cases. 

Reduction is accomplished by traction on the forearm in adduction 
with direct pressure inward on the head of the radius, after which the 
forearm is flexed and held in position. If pain, restriction of motion, 
or loss of supination are present, the reduction may be attempted by 
open operation. In those cases in which manipulation fails and in 



33 



» Beilage zum Centralbl. f. Chir., 1886, xiii, 93. 

' Ibid., p. 91. 

' Arch. f. kiin. Chir., w-i, 643. 



514 DISLOCATIONS OF THE ELBOW 

old standing cases with thickening about the head operation is the 
only recourse. The prognosis is good; operated cases with resection 
lead to fair functional results. 

DISLOCATIONS OF THE ULNA ALONE. 

There are a few cases of undisputed isolated dislocation of the 
ulna at the elbow. The close attachment of the two forearm bones 
by the strong interosseous ligament, the blending of the ligaments 
at the elbow-joint, and the relative impossibility of directing force 
on one bone to the exclusion of the other make these luxations 
extremely rare. They are divided into dislocations backward and 
forward. One isolated inward dislocation exists in the literature/ 
a case of open and infected luxation with diagnosis delayed for over 
forty days. The misplacement of the ulna may have arisen from 
secondary causes in the infection and softening of the capsule and 
ligaments. 

Backward Dislocation. — Backward dislocation of the ulna alone 
may also be partially outward, so that the coronoid lies just on the 
edge of the trochlear surface or completely behind it, and rising above 
the lower end of the humerus, lies in the olecranon fossa. I have seen 
this condition in one case of old posterior elbow dislocation which 
was reduced by open operation. The radius remained in position, 
but the ulna was slightly displaced backward, so that the coronoid 
did not come completely around in front of the trochlea, and flexion 
of the forearm was limited. An old complete dislocation of the ulna 
with rotation around the head of the radius was reported by War- 
basse.^ The patient was a thirteen-year-old boy who jumped from a 
wagon and fell, striking on the forearm and elbow. Deformity in the 
elbow was obscured by the swelling, but an examination nine weeks 
later demonstrated that the ulna was absent from the trochlear sur- 
face of the right elbow and the radius was in its normal position. 
Flexion and extension of the forearm was possible only through an 
arc of 10 degrees and flexion was limited beyond an angle to 150 degrees. 
Supination and pronation were only one-fourth normal and were 
painful. There was atrophy of the forearm. At the operation for 
reduction the ulna was found rotated 90 degrees and the sigmoid 
notch looked inward. A bony mass of new callus beneath the stripped 
up periosteum of the humeral condyle was chiseled off and the ulna 
was easily rotated back into its normal position. Extension and 
flexion became satisfactory but not quite full. 

The causes are falls on the outstretched hand or direct pressure 
on the partly flexed rigid forearm. Usually the arm has been in com- 
plete extension; flexion is not possible, but pronation and supination 
are. The forearm is in slight adduction, like a gunstock deformity, 
which must exist to permit the ulna to slide backward and the radius 

1 Loison, Arch, de Med. et Pharm., Mil., September, 1890. 

2 Ann. of Surg., Hi, 215. 



SUBLUXATION OF THE HEAD OF THE RADIUS 515 

to remain in ,'^itu. The position can be determined by inspection when 
the two elbows are compared. Little is known of the pathology. The 
internal lateral ligament is probably torn widely; the coronoid may 
be fractured. The brachial artery may be ruptured, and the orbicular 
ligament may not be torn unless the displacement is great. 

Sjmtiptoms. — The symptoms are those of a forearm in rigid extension 
with some adduction deformity. Flexion is not possible. The elbow 
is thickened in an anteroposterior diameter, and the olecranon can 
be palpated higher up than normally on the rear of the joint. The 
radial head is in position and rotates with the forearm, and the edge 
of the trochlea, which seems to be tilted outward, fills the space in 
the front of the elbow. There is no crepitus, the rigidity, palpatory 
findings, and roentgenogram make the differentiation from epitrochlear 
and dicondylar fracture. 

Treatment. — Reduction is performed by the attendant hyper- 
extending the forearm, supinating it and swinging it up into flexion. 
As an aid during the maneuver, pressure can be made over the 
olecranon. If manipulation fails, operation as described under Old 
Elbow Dislocations will be necessary. 

Forward Dislocations. — Two cases have been recorded, one by 
Stimson^ and one by ^Yight.- The internal lateral ligament and the 
flexor group of muscles were torn from the humerus, allowing lateral 
mobility of the elbow with some flexion and extension. The olecranon 
tip lay in front of and below the trochlea, and the inner anterior 
articular surface of the humerus could be felt by depression of the 
skin over the elbow. Reduction was easily performed by backward 
rotation and adduction of the forearm. 



SUBLUXATION OF THE HEAD OF THE RADIUS. 

This injury is quite common, and as it occurs exclusively in small 
children it is entitled to a separate description. Some of the older 
writers reported series of as many as 200 cases, but at the present 
time in hospital practice the cases are not frequent. Those which 
occur are either spontaneously reduced, cared for by the nurse and 
mother, or are reduced by the general practitioner in the course of 
his examination of the elbow. These subluxations occur in children 
from two to four years of age, although I find one case, recorded by 
Tubby^ in an eight-year-old boy. The cause is lifting or jerking on 
tlie forearm and wrist by the nurse as the child is walking and a sudden 
jerking catch by the wrist traction as the child stumbles. P'orearm 
pronation probably does not become a factor in the cause, for at the 
time of occurrence the child's arm is fully extended and the elbow- 
joint is firmly fixed, pronation and su})iT)ation in that position taking 
place at the shouhler. 

' Fractures and Dislocations, 7th edition, p. 718. 

2 Brooklyn Med. .Jour., September, 1H89. 

3 Clin. Jour., London, 1912-13, xl, 162. 



516 DISLOCATIONS OF THE ELBOW 

INIany theories of the cause have been advanced since the first good 
description by Duverney/ but the present opinion of surgeons seems 
to favor his original explanation. The condition is probably nothing 
more than an elongation of the radius in infants caused by the forcible 
traction on the wrist, which pulls the head downward away from 
the humerus. One must recall that, although the centre of ossifica- 
tion of the capitellum appears in the first year of life, the bones of 
the forearm and arm are widely separated in a roentgenogram by a 
cartilaginous area. Traction may easily cause longitudinal displace- 
ment of the radial head, with stretching of the loose and poorly devel- 
oped capsule and orbicular ligament. The head of the bone is luxated 
below the annular ligament and is held there. 

Symptoms and Diagnosis. — The symptoms are diagnostic. The 
child has immediate pain, often not only in the elbow but also in the 
wrist. The forearm is held motionless in pronation, hanging at the 
side, or flexed across the trunk if the patient is lying down. All active 
use of the elbow-joint is interdicted, and the child does not wish the 
arm touched. There are no definite findings on examination of the 
elbow, no swelling and little if any displacement of the radial head 
can even be noticed. There is tenderness on manipulation of the 
elbow-joint, and supination of the forearm is limited. 

Treatment. — As previously indicated, the reduction may occur spon- 
taneously, or the attendant in rotating the forearm may unconsciously 
force the head back into place. If there is sudden cessation of pain, 
and the child begins to use the arm, one may know that reduction has 
occurred. Many cases are misunderstood, are not diagnosed, but as 
the spontaneous reduction follows and function is restored the inci- 
dent is forgotten, and the success in Chassaignac's cases, which were 
treated as nerve lesions, could doubtless be traced to the spontaneous 
reduction. Chlumsky^ found that palpating and bending the elbow 
produced reduction. He found in one case a slight swelling over the 
radial head. Supination of the forearm with a slight upward push on 
the radius followed by flexion reduces the luxation, and function is 
generally resumed at once. A sling may be worn for a few days, or 
the arm can be pinned to the dress. In removing the child's clothing, 
hyperextension of the forearm should be avoided thereafter and there 
seems to be little tendency to recurrence, unless the upward jerk is 
repeated on the extended arm. The case of Tubby's referred to was 
subjected to operation because the posterior interosseous nerve was 
pressed upon, and the opposite elbow was showing symptoms of 
relaxation with a tendency to the same deformity. It was therefore 
considered best to cut down on the radial head and restore the orbicular 
ligament by means of an artificial silk ligament. 

1 Maladie des Os, 1751. 

2 Ztschr. f. Orthop. Chir., Stuttgart, 1911, xxix, 213. 



CHAPTER XIX. 

FRACTURES OF THE CARPAL AND IMETACARPAL 
BOXES AND PHALANGES. 

FRACTURES OF THE CARPAL BONES. 

These bones are so closely packed together and so inaccessible to 
the usual methods of examination that fractures of them, in addition 
to being rare, have been seldom reported prior to the era of the Roent- 
gen rays. Before 1896 many authorities, as Malgaigne (1850), Barden- 
heuer (1888) and Hoffa, considered that most fractures of the navicular 
bone were open and were accompanied by much laceration of the soft 
parts. With the help of the Roentgen pictures the literature is now 
furnished with many reports of fractures of individual bones or frac- 
ture and dislocation of one or more. The author desires to set out 
briefly a few important facts in connection with these fractures to 
attempt to simplify the subject for practical purposes. 

Since dislocations frequently complicate carpal fractures or are 
a part of them, it is difficult to separate descriptions of each type of 
injury, and they will consequently often be found together. In the 
author's series of 10,702 fractures investigated at the Cook County 
Hospital, 22 fractures of the carpal bones were found. 

Palpation of the wrist gives meager information as to the location 
and condition of the carpal bones, and on the ulnar side below the 
styloid process the pisiform can be felt projecting as a lump at the 
base of the palm on a level with the lowest transverse crease in the 
wrist. Below the radial styloid, at the base of the thumb metacarpal, 
the greater multangular bone can be grasped between the examining 
fingers. Other anatomical landmarks on the external surface consist 
in transverse lines. One drawn straight across on the level of the 
hamate bone crosses the capitate bone just above the base of the 
third metacarpal. If the hand is flexed after this line is drawn, a 
finger resting on this spot feels the head of the capitate bone slip into 
the space. The lower surface of the lunate bone lies just proximal to 
this. 

The midcarpal joint line, between the two rows of carpal bones, 
is not so straight as the wrist-joint surface, and although it is also 
transverse to the long axis of the arm, it reaches an abrupt stop when 
the outer side of the capitate bone is approached. Here the navicular 
bone intervenes, and if the midcarpal joint line were continued directly 
outward it would cut through its middle. 

Navicular Bone. — Fracture of this bone is now well recognized 
from many roentgenograms and reports of operated cases. It occurs 



518 FRACTURES OF CARPAL AND METACARPAL BONES 



as about 0.5 per cent, of all fractures and possibly oftener. Develop- 
mental variations must be considered before diagnosis is made posi- 
tively even by the Roentgen rays, and reference to such works as 
Dwight's^ should be made. The navicular bone develops from two 
centres of ossification which may never fuse. This non-fusion was 
reported in 1865 by Gruber, and the bipartite bone was then considered 
an arrest in development. Wolffs calls one the cubital and the other 
the radial navicular and asserts that they are found in 0.5 per cent, 
of people examined. He reports 47 cases, 30 in men, 11 in women, and 

6 not stated. Nine of these cases were bilateral, 20 in the left wrist and 

7 in the right wrist alone. If the division line is directly in the middle, 

and there is no traumatic history, 
and the roentgenogram shows a 
clear interval between the bones 
with regular smooth edges, a con- 
genital separation is possible. If 
the division lies to one side or other, 
decision is not so easy, and the 
possibility of old ununited fracture 
must be considered. It seems prob- 
able that the trauma which would 
cause a fracture would not go un- 
noticed (Fig. 330). A case of con- 
genital division simulating frac- 
ture in a nineteen-year-old patient 
has been reported by Mouchet.^ 
The left navicular was bipartite, 
and the ring finger was longer than 
the middle finger. Hirsch^ believes 
that the so-called bipartite bones 
nearly all have their origin in frac- 
ture, as the latest collections of frac- 
ture statistics, aided by Roentgen- 
ray examination, demonstrate that 
out of ten radial fractures there 
navicular fractures. The records 
of the Cook County Hospital do not bear out this high proportion. 

Fracture occurs most frequently in the third and fourth decades, 
and usually follows falls on the palm as in Colles's fracture. The 
injury is often mistaken for Colles's fracture, or the two may occur 
simultaneously. Most fractures are through the neck of the bone, 
but in others the plane of fracture passes more toward the medial 
side (Fig. 331), so that the bone is divided into a smaller proximal and 
a larger distal fragment (Fig. 332) . Laborers and adult males are those 




Fig, 330. — Transverse fracture of the 
navicular bone. This case might be 
mistaken for a bipartite bone. 



are one or two accompanying 



1 Variations of the Bones of the Hand and Foot. 

2 Deutsch. Ztschr. f. Chir., B. 69, 1401; Bd. Ixx. 289. 

3 Revue d'Orthop., 1914, 3 S., v, 201. 

'' Ergebnisse der Chir. und Orthop., Bd. viii, 71<S. 



FRACTURES OF THE CARPAL BONES 



519 



most frequently concerned, and the right hand is more often involved, 
as it is thrown out to break a fall. There are a few instances of bilateral 
fracture. 

The mechanism is as much disputed as that of Colles's fracture. 

Three principal methods suggested are : 

1. Force of indirect violence from falls on the dorsally flexed hand 
or a falling body striking on the palm when the forearm is flexed 
is the first type of mechanism. From the brief description of the mid- 
carpal joint given above, it is seen that on account of the position of 
the na^'icular, which interferes with a direct transverse line, it may be 
considered as belonging to both rows of carpal bones. If the wrist 
is flexed or extended, the second row of carpal bones makes an angle 
with the first row, and the navicular, in attempting to accommodate 
itself to both rows, is broken across the line of the midcarpal joint by 





Fig. 331. — Fracture of the navicular 
Yyone \Nath separation of fragments. 



Fig. 



332. — Fracture of the navicular bone 
with unequal fragments. 



the strain. This mechanism is verified in those cases of midcarpal 
dislocation and fracture of the navicular in which the proximal frag- 
ment remains with the first row and the distal fragment is displaced 
with the second row. In violent adduction of the hand, the navicular 
may be strained across the radial styloid and broken, the styloid 
breaking also. 

2. Compression force applied to the two extremities of the bone 
when the hand is in extension or flexion and forced abduction against 
an object is the second type of mechanism. The capitate bone presses 
against the distal portion of the navicular and the object on the inner 
side presses against that portion with a resulting force which tends 
to straighten out the bone, which breaks as a result. A blow on the 
thenar eminence in falling causes compression of the two rows of 
carpal bones between tlic joint surfaces of the radius and the hand. 



520 FRACTURES OF CARPAL AND METACARPAL BONES 



The head of the capitate bone forces against the inner part of the 
na^'icular and the lunate, and the force is transmitted up to the radius 
if the hand is straight in the forearm axis and not abducted. This 
leads to an ordinary Colles. //, however, the hand is more abducted 
and extended, the force passes inward toward the styloid process, 
crushes the lower end of the radius and impacts it. The pull on the 
lateral ligament is frequently of such character that the styloid process 
is torn off or shoved off, and the navicular and lunate bones are com- 
pressed and possibly fractured. The softer structure of the navicular 
bone yields between the more solid capitate and radius (see Figs. 333 
and 334). 




Fig. 333. — Illustration of the transmis- 
sion of force through the third metacarpal 



Fig. 334. — Illustration of the transmis- 



to the forearm via the navicular, the hand sion of force to the forearm via the lunate 
being in radial flexion. (Adapted from bone; hand in ulnar flexion. (Adapted 



Hirsch.) 



from Hirsch.) 



3. Direct violence suffered in falls on the back of the hand or by 
from a blow may cause fracture. 

Clinically, there are two main- classes of fracture which are important 
in cause, prognosis, and treatment. They are: 

1. Fracture of the body, usually transverse to the long axis of the 
bone through its weak centre or neck. 

2. Fracture of the tuberosity of the navicular bone. 

Type 1 is an intra-articular or joint fracture, as the joint cavity 
is opened (see Fig. 335), but 2 is strictly extra-articular (Fig. 336). 
Fresh fracture through the body shows a line of separation, as in 



FRACTURES OF THE CARPAL BONES 



521 



ordinary transverse lesion of bone, but the older cases have been 
subjected to absorption of the cancellous portion by the influx of 
synovial fluid and the irritation of use, so that a distmct cavity is 
often found in the roentgenogram. Formerly this was considered a 
condition of osteitis in the navicular bone followed by fracture, and 
cases have been reported by Preiser,^ but we now know that the 
fracture precedes the bone absorption. Murphy^ believes that the 
transverse fracture is sometimes impacted and names that as a dis- 
tinct type of navicular fracture which leads to the absorption of bone 
and cavity formation. The degree of crushing of the bone in the 
fracture varies, but the fact that it is split, the vascular supply is 
interfered with, and the cancellous tissue is exposed to the joint fluid 





Fig. 335. — Fracture of the tuberosity 
of the na\icular bone. 



Fig. 336. — Illustration of the extent and 
location of the synovial surfaces of the wrist. 
The tuberosity of the navicular is seen to lie 
outside of the synovial surface. 



has much to do with the appearance of bone absorption in the later 
roentgenograms. Some cases with simple transverse splits heal 
readily and promptly by bony union. I had such a case this winter. 
Others, on account of the supposed comminution or the rupture of 
the periosteum and synovial surface, are exposed to the irritation of 
the joint fluid, and bone absorption results (Fig. 337). Guye records 
7 similar cases afl'ecting the lunate bone.^ 

Fracture of the tuberosity is less frequent than that of the body and 
is an avulsion caused by falls on the forearm, the hand flexed to 90 
degrees and strongly abducted, so that the radionavicular ligament 
pulls out its attachment to the navicular (see Fig. 335). This 



• Fortschritte auf d. geb. d. Roentgeristr., 15, Heft 4. 

2 Clinics, iv. No. 3. 

' Deutsch. Ztschr. f. Chir., Leipzig, cxxx. 



522 FRACTURES OF CARPAL AND METACARPAL BONES 

mechanism has been experimentally verified by Cousins and also by 
Gallos.i 

A difference in the position of the hand at the time the individual 
receives the trauma of the fall undoubtedly has much to do with the 
type of lesion. If the hand is in radial flexion and the force is received 
on the palm, it is transmitted through the middle metacarpal via the 
carpal bones to the radius, catching and crushing the navicular (see 
Fig. 334, adapted from Hirsch). Should the hand be in ulnar flexion 
this same violence is transmitted through the lunate bone and it is 
usually dislocated. The navicular escapes because it lies farther out- 
ward in this position between the radial styloid and the wrist bone 
of the second row, presenting its long axis in the direction of the trauma. 

Symptoms.— -The immediate symptoms are much like those of a 
sprained wrist except that there is greater rigidity. If a fragment of 




Fig. 337. — Old fracture of the navicular, showing bone absorption, cavity formation 
and open articular changes about the wrist which lead to great restriction of motion. 



bone is displaced, and tenderness in the tabatiere is elicited on slight 
pressure, there may be visible sign of injury and pain does not seem 
disproportionate. Swelling of the wrist below the styloid line and the 
end of the radius is quite constant, and there is loss of power of the 
hand grip and limitation of motion at the wrist, particularly extension 
and rotation. Crepitus and ecchymoses are not frequently found. 
Downes^ obtained crepitus in 2 out of 10 cases. Codman and Chase^ 
did not find either in 30 cases. It is necessary to compare with the 
uninjured wrist to ascertain the normal limitation of motion, which 
averages as follows : 

Dorsal flexion, about 45 degrees. 

Volar flexion, 60 to 70 degrees. 

Ulnar flexion, 40 degrees. 

Hadial flexion, 20 degrees. 



These de Lyons, 1897, 1898. 



2 Ann. of Surg., xlvii, 72. 



3 Ibid., xli, 721. 



FRACTURES OF THE CARPAL BONES 523 

The cavity of the tabatiere, which hes between the extensor polHcis 
longiis on one side and the extensor pollicis brevis and abductor 
polHcis k^ngus on the other side, is early filled or obliterated by swell- 
ing, and the radius and ulna are discovered to be normal, with the 
styloids in usual relation. The carpus may appear shortened on the 
radial side, and an additional test of value lies in striking a light 
blow on the knuckle of the third metacarpal at the base of the finger 
while the hand is in radial flexion. The surgeon stands with his body 
between the patient and the patient's hand, so that the blow cannot 
be anticipated. This blow causes pain in the wrist if the navicular 
is broken, while it does not if the hand is in ulnar flexion unless the 
lunate is broken. The percussion test is valuable in differentiation 
of navicular fracture and lunate fracture and dislocation. Tapping of 
the first and second metacarpals causes some pain in the wrist when 
the navicular is injured, but not so much as does that of the third 
metacarpal when the hand is held in radial flexion. The fourth and 
fifth metacarpals are not tender at all, because they do not transmit 
the force to the radius via the navicular and lunate bones. With the 
hand in ulnar flexion the pain is absent when the percussion test is 
applied for fracture of the navicular, but it is positive for fracture or 
dislocation of the lunate bone, though less in dislocation than fracture. 
Differentiation from sprained wrist lies in the greater area of soreness, 
which is quite evenly distributed about the wrist, and fracture of 
the radius is diagnosed by a swelling higher up and the tender styloids. 

Sprain fractures of the radius, or injuries followed by a bursitis at 
the wrist or a synovitis in the sheath of the extensor carpi radialis 
brevis and extensor pollicis longus, are difficult to differentiate, as no 
ecchymosis may appear and there is a circumscribed swelling at the 
lower end of the radius which tends to spread upward. The tabatiere 
is not tender. 

The roentgenogram is needed to confirm the diagnosis. This should 
be taken of both hands on the same plate with the tube midway 
between them so that the question of bipartite bone can be answered 
at once. 

Course and Prognosis.- — If the condition is recognized at once and 
treated by immobilization, in fractures of the body without dis- 
placement of fragments bony union may occur. If the injury is not 
treated there remains rigidity and pain iti the wrist, atrophy first of 
the hand and then of the forearm muscles, and persistent pain on 
pressure in the tabatiere. In the intra-articular fractures absorption 
of bone follows from the action of attempted use and the constant 
bathing of the fragments by synovial fluid on their cancellous surface. 
The eff'ort at callus formation is little or nothing, because most of 
the small nutrient vessels which enter the bone in the middle, the 
usual site of fracture, are torn, and as the cancellous surfaces have 
no periosteal covering, no union results; even fibrous union is rare. 
A pseudarthrosis develops. If a fragment is displaced to interfere 
with wrist motion, stiffness results from hick of use and the thickening 



524 FRACTURES OF CARPAL AND METACARPAL BONES 

and changes induced in the wrist capsule. Small exostoses may develop 
from the radial surface into the joint capsule, or a bone atrophy or 
ebiu'uation, with shrinking of all capsular structures. Use of the 
wrist is more and more restricted with lessened hand grip, constant 
pain, obliterated tabatiere and an atrophic forearm. 

Prognosis. — Prognosis of fracture of the tuberosity is good, as this 
is an extra-articular affair which heals in a short time, with no inter- 
ference with the wrist-joint. There is a normal callus. 

The final condition demands a year to be realized, and changes 
for the worse in unhealed cases of body fracture occur within that 
period. Blau studied 15 cases in soldiers and found that the loss 
of function equalled 33 per cent., but as he observed them only a 
few weeks he did not obtain final results.^ 

Treatment. — Tuberosity fractures, being extra-articular, are best 
treated by massage and passive motion. They should not be immob- 
ilized unless there is great pain and then for a few days only; use and 
motion must be insisted on, and heat should be employed. 

Immediate treatment of body fractures depends on the displace- 
ment of fragments. If there is none, the hand is treated by immob- 
ilization for at least three weeks in a position of slight volar flexion, 
as this brings the fragments into closer apposition.^ If a fragment 
is displaced on the dorsum, the wrist is acutely flexed, firm pressure 
is made on the back of the hand, and the joint is then completely 
hyperextended. If reduction fails by this method, Jones^ advises 
immediate removal of the dislocated fragment or the whole bone. On 
the basis that few bony unions result, one seeks, by means of movement, 
use, and massage treatment, to establish a false joint. This obtains 
but poor results. Neglected cases which refuse operative treatment 
may be improved by the hand being fixed in hyperextension, with 
the use of a wrench if necessary, as the hand grip has been weakened 
because extension is limited, the power of the grip being greater in 
a position of extension. A case of fracture of the navicular with luxa- 
tion of the lunate bone reduced by manipulation was reported by 
Skillern.^ He made a reduction in accordance with the method of 
Codman and Chase,^ and immobilized the wrist for four weeks without 
massage. The functional recovery was good, although it is not stated 
how long the patient was under observation and his criticism of Cor- 
ner's case, seen eighteen months after a similar fracture, is not war- 
ranted. The latter's case after this period of time had greatly limited 
wrist motion, an obliterated tabatiere, and a prominence over the 
distal part of the carpus. 

The results of all methods of treatment lead to the conclusion 
that if a dislocated fragment cannot be reduced it should be excised 
at once (Figs. 338, 339, and 340). 

1 Deutsch. Ztschr. f. Chir., 1904, Ixxii, 

2 Ehebald, Arch. f. Orthop., 1906, Heft 3. 

3 Proc. Roy. Soc. Med., England, December, 1910. 

4 Ann. of Surg., Iviii, 716. & Ibid., xli, 321, 863. 



FRACTURES OF THE CARPAL BONES 



525 



Operative Treatment. — Old cases with stiffened wrists and restricted 
function, pseudarthrosis between fragments, with other bad end- 
results or persistent pain, should be operated upon. 




^^-a-Q^-^^HhOr-O-^o-^ 




Fig. 338. — Removal of a frac- 
tured navicular. The surgeon failed 
to notice that the lunate was dis- 
located. 



Fig. 339. — Side view of the preceding. Navic- 
ular removed and lunate present dislocated 
toward the palmar surface. Clips in skin 
wound on dorsum of hand. 



Xo raw bone surface on a fragment should be left behind, and all 
fragments should be removed, especially in young adults or working 
people. Skillern^ records one case treated by bloodless reduction and 
four weeks' immobilization with a good 
result. Hitzrot^ removed the navicular 
and dislocated lunate bone in an acrobat 
who was enabled to resume his occupation 
without pain. Hirsch reports fifteen cases 
radically operated on, some of four years' 
standing, and all with very good results, 
and "Wallace^ one case with dislocation 
of the lunate, excision of which, with the 
proximal fragment of the navicular, gave 
a good hand. Another case recorded by 
Jaboulay,"* was complicated by paralysis of 
the median nerve and atrophy of the thenar 
eminence cau.sed by a dislocated fragment 
of the navicular. The paralysis had not 
improved much one and a half months 
after the removal of the bone. 

Technic of Removal, — The incision to 
approach the bone may be on the dorsal 
or palmar surface of the wrist, or on the 




F'iG. 340. — A second opera- 
tion on the preceding for re- 
moval of the lunate. Both of 
the proximal row of carpal hones 
are now gone. 



> Ann. of Surg., Iviii, 716. 

3 Lancet, March 22, 1913. p. 819. 



Ibid., Hi, 201. 

Lyon Med., 1913, cxxi, 699. 



526 FRACTURES OF CARPAL AND METACARPAL BONES 

internal lateral side. The dorsal approach is the simplest. An inch long 
incision is made on the radial side of the wrist parallel to the border of the 
extensor carpi radialis, the tissues are retracted, the annular ligament 
is cut through between the extensor tendons with care not to open 
them or the bursse, and the proximal fragment of the bone is cut 
down upon. A small hook is inserted between the fragments and they 
are pried or lifted out. The author believes both fragments should 
be removed. A suture of fine catgut may be put in the annular liga- 
ment, although it does not tend to gape, and the wound is closed 
tightly. After-treatment consists in immobilization for a week, 
followed by use and massage. If the fragment has been displaced 
forward, it can be reached through the palmar incision. It is never 
necessary to excise the whole proximal row of carpal bones in prompt 
operative care. 

Lunate Bone. — Fractures of the lunate bone are often open, follow- 
ing severe injuries to the wrist. Closed fractures are caused by falls 
or direct violence, especially cranking or back-fire injuries, with 
the same mechanism as described in the navicular bone, the hand 
being held in ulnar flexion to transmit the violence through the lunate 
to the radius. Four cases were reported by Finsterer,^ and he made 
a collection of 33 others. The physical examination is very unsatis- 
factory; the lesion may be suspected, but nothing is definitely known 
until a dried roentgenogram is studied. Percussion pressure on the 
middle metacarpal bone, the hand in ulnar flexion, the most reliable 
finding and pencil-point tenderness over the semilunar bone with no 
apparent displacement are symptoms. (See picture of the navicular 
bone.) 

When the bone is crushed there is generally shortening of the carpus. 
This is demonstrated by observation and mensuration. The distance 
from the styloid of the radius to the head of the middle metacarpal 
is found shortened when compared to the other hand, and the surgeon 
may be able to see that the knuckle of the third metacarpal, which 
is always the most advanced and prominent, has been shortened, and 
lies on a level with the other metacarpal heads. The whole wrist 
may be thickened but not so much as in dislocation of the lunate bone, 
nor is there as much limitation of motion as in dislocation. Dorsal 
flexion is more interfered with than palmar flexion, but as the finger 
tendons are less displaced and pressed upon by a fractured bone than 
by dislocated lunate the function in the former condition is less affected. 
In dislocation also the median nerve may be pressed upon, and pain 
or trophic disturbances develop in its peripheral distribution. Frac- 
ture rarely involves the nerve. 

The question of diagnosis and treatment of these lunate and navic- 
ular fractures is important from the standpoint of function and also 
for medicolegal reasons. We know that undiagnosed or untreated 
fractures of the wrist bones cause changes which may extend over a 

1 Beitr. z. klin, Chir., Ixiv, 85. 



FRACTURES OF THE CARPAL BONES 527 

period of years and end in stiffened wrists with functional loss. If 
the condition is diagnosed as sprain and use is continued, we may 
expect these late complications. 

A condition known as isolated disease of the lunate bone has been 
noted. It is also called Kienboch's disease, after the first describer. 
A severe trauma to the hand and wrist does not seem to be essential, 
and the patient may forget that he injured himself, as he seldom 
stops work on account of it. Some time later pain and swelling appear 
in the wrist, accompanied by limitation of motion and loss of strength. 
A roentgenogram is generally taken at this time, the bone structure 
is observed to be less firm, the edges are crumbled away, and the 
whole lunate bone may be broken into two or three fragments (see 
Fig. 342). A question then arises whether the person suffered an injury 
at work and is entitled to damage under a compensation act, or 
whether the diseased condition of the bone has been caused by trauma 
which occurred outside of his work. Kienboch made careful examina- 
tion of more than 1400 \\Tist-joints and concluded that the disease 
can occur without trauma severe enough to cause the patient to cease 
work at once. The pathology probably depends on interference with 
the blood supply which arrives at the bone via the ligaments. When 
a slight trauma is received the ligaments may be torn, the bone nour- 
ishment is interrupted, and the absorption begins. Primary fracture 
often causes the same results because of the impeded vascular supply 
and the poor osteogenetic properties of the bone. Consequently 
every case of vn:ist injury which involves workmen's compensation 
or employer's liability should be exposed to roentgenogram and care- 
fully diagnosed. Becker^ has added 20 cases to the literature, and he 
concurs with Kienboch's ideas. Frenkel-Tissot^ reports 2 cases, 1 seen 
four and one-half years after an injury which had originally appeared to 
be a fissure across the radial epiphysis. Both of these cases had limited 
motion, with pain and tenderness in the wrist, and the roentgeno- 
grams showed irregular bone structure, flattening and decreased size 
of the lunate bone. A microscopic examination of 1 case showed a 
compression fracture following after the original nutritional disturb- 
ance of the bone. 

As stated under navicular fractures, the lunate bone is more fre- 
fjuently dislocated than fractured, but as fractures of it are intra- 
articular, the results are much like those following body navicular 
lesions. Even in compression of the bone as recorded by Guye, 7 
cases, Granier,"^ 3 cases, and Gaza,"* 2 cases, the symptoms are much 
delayed and are probably caused by a slow process of bone atrophy 
and absorption from loss of blood supply, irritation, and the synovial 
fluid (Figs. 341 and 342). The persistent pain and loss of function 
coupled with the !{oentgen-ray findings of lighter areas at the time of 

> Beitr. z. klin. Chir., 1914, xciv, 172. 

2 Fortschr. der Rontgen Strahlen, 1914, xxi, .530. 

■i Doutsrh. mod. Wc-hnsr-hr., 1909, p. 928. 

' Miinchen. med. Wchn.sr-hr., Berlin, Ixi, No. 41. 



528 FRACTURES OF CARPAL AND METACARPAL BONES 

injury, or delayed secondary lime depositsand arthritic change make a 
diagnosis of fracture. Treatment of fresh fractures consists in immob- 
ilization of the wrist including extension of the third finger by straps 
or by a spring apparatus attached to the splint. Guye removed the 
bone early in two cases with good results. If the symptoms are latent 
for some time, a severe late secondary arthritis may develop which 
demands resection of the carpus. Operation is indicated in the face 
of these changes. The surgeon should be sure of the bone he is dealing 
with and make no mistake in removing the wrong one, or only a part 
of the damaged bone. This mistake happens, much to the chagrin 
of the operator when a roentgenogram is made later. 





Fig. 341. — ^^Recent comminuted 
fracture of the lunate bone. 



Fig. 342. — Old fracture of the lunate bone 
with absorption. The stiffness and disability in 
the wrist was supposedly caused by the piece of 
needle buried in it. The true trouble was ex- 
posed by the roentgenogram. Kienbock's dis- 
ease? 



Fracture of the Capitate Bone. — Glasmacher^ found but one instance 
of fracture of this bone at the Cologne City Hospital in five years 
among twenty carpal fractures. Moty^ says that the natural termina- 
tion of these fractures is ankylosis of both the great wrist joints. A 
case was reported by Harrigan,^ who states that there were but 5 
cases in the literature, one only confirmed by the roentgenogram.* 
The cause is direct violence over the bone, or indirect violence applied 
to the heads of the second and fourth metacarpal bones sufficient to 
cause sudden flexion of the wrist. If the posterior radiocarpal ligament 
is weak, a blow of this character results in a posterior wrist dislocation; 
if the ligament holds, the strain is exerted on the neck of the relatively 
immovable capitate bone, the head of which by rotation transmits 



Tnaug. Disser., Leipzig, 1906. 

Gazette des Hopitaux, 1890, No. 69. ' Ann. of Surg., xlviii, 917. 

Guermonprez-Monjaret Jour. d'Sci. Med. de Lille, 1904, xxvii. 



FRACTURES OF THE METACARPAL BONES 529 

force from the metacarpals to the carpal bones, and fracture results. 
The sjTQptoms are pain in the carpus, swelling over the bone, espe- 
cially on the dorsum, loss of function in the hand, and localized ten- 
derness. If the head is dislocated out of its position, it can be felt 
beneath the skin. 

Treatment. — Treatment consists in complete immobilization of the 
hand for three to four weeks. Excision is necessary for dislocated 
fragments or persistent symptoms. Destot^ said he had seen three 
cases but gave no details. 

Fracture of the Triangular Bone. — Isolated fracture of the triangular 
bone is rare. Coues^ reported a case in a woman, aged twenty-three 
years, who was standing on her hands in a gymnasium. She lost 
her balance and fell over, rolling on her left hand, which was flatly 
extended on the ground. Immediate pain and loss of function occurred, 
and she asserted that crepitus was present. Ecchymoses appeared 
with pain in the ^Tist, and lateral pressure against the pisiform caused 
transmitted pressure on the triangular with resulting tenderness. 
Immobilization on a palmar splint gave relief and bony union after 
two months. 

Fracture of the Pisiform Bone. — The pisiform is rarely fractured. 
The author has seen one case, an extra-articular crack which healed 
promptly. Deane^ reported a case in a man aged twenty-three years 
who fell down an elevator shaft. The mechanism was hyperextension 
of the \\Tist-joint with the hand adducted. The pull of the flexor 
carpi ulnaris was strong enough to cause a transverse fracture of the 
bone with the counter pull furnished by the ligamentous attachment 
to the triangular bone. There was crepitus on manipulation, and the 
roentgenogram confirmed the diagnosis. Other symptoms are pain 
in the bone when the flexors are contracted and local tenderness on 
pressure. Lesions of the bone which open the wrist- joint or which 
divide it in an axis parallel to the palmar surface may not result in 
bony union, for reasons expressed under the discussion of the navicular 
bone. 

Fracture of the Multangular and Hamate Bones. — The multangular 
and hamate bones are also rarely fractured. The author has seen one 
fracture of the greater multangular bone in connection with fracture 
of the navicular. 

FRACTURES OF THE METACARPAL BONES. 

These fractures are common, though not so frequent in hospital 
records because the patients do not remain there. Stimson quotes 
some figures from Paris hospitals before the Koentgen-ray period, 
which place their frequency about 1.12 per cent. In the 10,702 frac- 
tures reviewed at tlie ( Vjok County Hospital there were 208 fractures 

1 Verhdig. d. Deutsch. Roentgen. Ges., 1905. 

2 Boston Med. and Surg. .Jour., clxx, 579. 
3^Ann. of Surg., liv, 229. 

34 



530 FRACTURES OF CARPAL AND METACARPAL BONES 

of the metacarpal bones, nearly 2 per cent. Epiphyseal separa- 
tions are found in these bones, as in other long bones, and are more 
frequent than was believed before the Roentgen-ray examination 
became routine in injuries. Coues,^ in 1912, asserted that there are 
but 2 cases of epiphyseal separation of the first metacarpal as 
described by Poland,^ and he added another in a fourteen-year-old 
boy. Others have been recorded by Sturrock,^ 1 case, and Gasne'^ 2 
cases of the first and 4 cases of the other metacarpals. In the thumb 
there is usually but one epiphysis, at the base of the metacarpal bone, 
a fact which has led to discussion of the character of this bone and the 
possibility of its really being a phalanx. The other four metacarpals 
have epiphyses only at the heads of the bone. Epiphyseal separation 
of the first metacarpal is different from the so-called Bennett's "stave" 
fracture (see Figs. 343 and 344)^ which is an oblique fracture of the 





Fig. 343. — Bennett's fracture of the 
first metacarpal — thumb. 



Fig. 344.— a different type of Bennett' 
fracture of the thumb metacarpal. 



proximal end, the palmar fragment opening into the joint and the 
distal portion being separated and dislocated backward to a varying 
degree. The lesion simulates a dislocation of the thumb, and differen- 
tial diagnosis is usually determined by Roentgen examination. Many 
of the Bennett fractures are not more than a crack, sometimes received 
in blows on the thumb joint direct, or by an unexpected abduction. 
Rarely the bone is comminuted clear through the thickness of the 
shaft, and there is considerable displacement of the fragments. The 
causes are direct and indirect violence. One may incur the injury 
from blows of the fist, sudden falls with a slapping of the back of the 



1 Ann. of Surg., Ivi, 450. 

2 Traumatic Separation of the Epiphysis, 1898, p. 588. 

3 Edinburgh Hosp. Repts., ii, 603. 
* Rev. de Orthop., March, 1913. 

5 British Med. Jour,, July, 1886. 



FRACTURES OF THE METACARPAL BONES 



531 



hand against the ground, squeezes of the hand by being caught between 
heavy objects, direct pressure from suddenly appHed heavy weight 
when Ufting hirge objects, and shpping. Indirect violence of a torsional 
character may also cause these fractures. The bones most exposed 
to external violence, the first, second, and fifth, are naturally the ones 
most frequently injured. The middle bones are sometimes broken 
by indirect violence from the twisting of a finger, or a fall on an out- 
stretched finger. 

Symptoms and Diagnosis. — Sw^elling of the hand may mask the 
findings on examination. Severe pain on pressure over the bone or 
bones injured, when the corresponding fingers are extended or pressed 
toward the carpus, is sufficient evidence to w^arrant treatment as 
fracture. There may be false motion, and crepitus is almost always 
present, coupled with loss of function in the fingers. The roentgeno- 
gram Avill frequently reveal more than one bone broken (see Fig. 345) . 





Fig. 3-45. — Multiple fractures of the metacarpal 
bones. 



Fig. 346. — Fracture near base of 
the second metacarpal 



Displacements are not great on account of the muscles and the 
proximity of the bones (see Fig. 346). Near the head the distal frag- 
ment is usualh" displaced toward the dorsum and may override later- 
ally, so that dislocation of the finger backward must be differentiated. 
In the thumb, if there is a luxation at the base, the metacarpal is 
always displaced posteriorly, and the distal part is in flexion. If the 
fracture is crack-like, there may be no displacement, and epiphyseal 
separations difi'er in that the displacement is generally lateral instead 
of posterior, there is a muffled crepitus, and a greater tendency for 
the recurrence of deformity after reposition. The luxations of the 
other four fingers usually cause a hyperextension of the first phalanx 
and flexion of the last two, while in the epiphyseal separation all three 
phalanges are in extension. White, in Piersol's Anatomy, described a 



532 FRACTURES OF CARPAL AND METACARPAL BONES 

disjunction of the epiphyses of the fourth and fifth metacarpal bones 
in a lad aged fourteen years. This is a rare injury, because the meta- 
carpals of the index, middle and ring fingers are longer and subject to 
greater trauma. 

Union between fragments is generally complete in one month. 
Occasionally an angularity persists, or the callus may adhere to a 
tendon, giving a stiff and partly extended finger in the metacarpo- 





FiG. 347. — Fracture near the head of 
the second metacarpal. The phalanx has 
also been chipped. 



Fig. 



348. — Fracture near the head of 
the fifth metacarpal. 



phalangeal joint. If two neighboring bones are broken, they may 
become united together and impair the hand function. Non-union 
is extremely rare, and the usual result is satisfactory from a functional 
standpoint. 

Treatment. — Many of these fractures are open. If they are closed 
there is always swelling and edema of the hand and fingers, which is 
painful and throbbing in character. This demands first attention 
and is cared for by alcohol dressings and maintaining the hand in 



FRACTURES OF THE METACARPAL BONES 



533 



an elevated position or by the application of an ice-bag. Fractures 
with little displacement are treated by a small and well-padded palmar 
splint extending from the finger bases and abo^ e the wrist. If exten- 
sion of the finger corrects the deformity, the finger of the bone involved 
may be held in that position by the same splint. If possible, the 
fingers should be left free for movement to avoid stiffness. The palmar 
splint may be strapped on by adhesive which runs across the dorsum 




Fig. 349. — Pathological fracture of the fifth metacarpal. The thumb and wrist have also 
been invaded by the carcinomatous process. Case of Dr. D. D. Lewis. ■ 



of the hand and helps hold the fragments in position. Fractures of 
the second and fifth bone should not be bound on to a palmar splint 
by a roller bandage, as this tends to cause lateral displacement. Plaster- 
of-Paris encasements are also used after the initial swelling is gone, 
as they provide secure protection to the hand from knocks through 
its brushing against oV)jects. 

Fractures near the head of the outer four metacarpals give trouble- 



534 FRACTURES OF CARPAL AND METACARPAL BONES 

some displacements and are difficult to hold in reduction (Figs. 347 
and 348). A ball or a wad of padding placed in the palm makes an 
admirable dressing, the hand being strapped on it. The position of 
the fingers in flexion pulls the metacarpal joint at the finger base into 
position. Extension placed on the finger by adhesive fastened to a 
spring dressing on a palmar splint may reduce the deformity, but 
the finger joints do not tolerate this type of dressing very well. Rarely 
operative interference may be indicated for cosmetic or functional 
reasons. Simple reposition of fragments is the best method, approach 
being made on the dorsal side of the hand. Wiring has little value 
over reposition, as the wire often fails to hold the adjustment if the 
fragments will not remain in position by replacement and splinting. 
An extra epiphysis sometimes appears at the base of the second 
metatarsal. It may be separated. I have seen one case incidentally 
discovered in the roentgenogram. Skillern^ has recorded a case. 

Bennett's fracture requires special treatment. If there is little 
displacement, the thumb is held in slight abduction by a plaster spica 
encasement run down onto the hand, to protect it from movements 
or jars while healing. If displacement is greater, traction may be 
maintained in abduction by an adhesive extension applied to a splint 
fastened to the palm or buried in an encasement on the hand. Gen- 
erally traction on the thumb with pressure inward at the base affords 
a satisfactory reduction, and a plaster spica or palmar splint holds the 
reduction. This should be left on about three weeks and motion 
then started (Fig. 349). 

FRACTURES OF THE PHALANGES. 

The phalanges are broken by direct or indirect violence in crushings 
or gross injuries of the hand and fingers, or in squeezes between heavy 
objects. Many are open fractures and must be dealt with accordingly. 
Indirect violence causes fracture in twisting of one or more fingers 
or sudden hyperextension, as in falls and pushes or baseball injuries. 

The proximal phalanx is most frequently broken, and the displace- 
ment is usually not great, as the line of fracture tends to be trans- 
verse. Comminution in direct violence occurs, and small lines of 
fractures may be evident in the roentgenogram which are not antici- 
pated clinically (Fig. 350). The author has had one case of oblique 
fracture from palmar to dorsal surface in the distal phalanx of the 
little finger of a heavy woman. This was caused by her catching the 
finger on the casing of an automobile door as she was getting out, 
her momentum carrying her forward and causing her whole weight to 
be suspended by the end of the little finger. 

Symptoms and Diagnosis. — The symptoms are pain, false point of 
motion in the continuity of the phalanx, and crepitus, which can 
always be felt if there is complete fracture. Diagnosis is easily made. 

lAnn. of Surgery, March, 1915, p. 374. 



FRACTURES OF THE PHALANGES 



535 



Each phalanx of a finger can be taken deHcately between the index 
finger and thnmb of each hand and carefully rocked for evidence. 

Bony union is the rule if the fracture is not open and infected. 
Hartmann^ recorded a case of non-union with deformity after fracture 
of the proximal phalanx of the thumb treated for six weeks on a card- 
board splint. He freshened the fracture plane by operation and 
obtained a good result. If infection sets in, the finger should be widely 
opened and ample drainage provided, and the bone early removed 
in its entirety, leaving periosteum behind for regeneration. The finger 
will shorten after this procedure, if it is not held in extension, but 
the suppurative process stops quickly. The distal phalanx should be 
removed at first evidence of osteomyelitis following its fracture — it 
does not regenerate. Long-continued suppuration and drainage often 
lead to amputation. Secondary amputation may be done later to 




Fig. .350. — Transverse fracture of the 
proximal phalanx of the index finger. 



Fig. 351. — Goldthwaite's thumb splint 
cut out of sheet metal and folded to fit 
thumb. 



get rid of a contracted and deformed finger which is stiff and really 
interferes with hand function. In the case of the thumb, every effort 
should be made to preserve all of it. 

Treatment. — With no displacement the finger may be strapped to 
its fellows in extension, and union will be prompt (P'ig. 351). Strapping 
is removed completely in two weeks. Padded wooden tongue depres- 
sors make good splints for fractures of the two distal phalanges. 
Such a splint can be fixed to the palm by strapping and the finger 
lightly bandaged on. The splint should be extended beyond the end 
of the finger to ward off' all jars. \'arious extension dressings made 
by applying adhesive tape spirally to the finger distal to the point of 
fracture have been devised. These are valuable in fractures of the 
proximal phalanx. 

I Ztschr. f. orthop. f'hir., 1014, Bd. xxxiv, Heft .3-4. 



536 FRACTURES OF CARPAL AND METACARPAL BONES 

The iiiterossei muscles tend to flex the proximal phalanx in extend- 
ing the distal two, and their action causes a forward displacement of 
the proximal fragments in fracture of the proximal phalanx. This 
results in an angularity, directed forward, which may interfere with 
the hand grasp. These fractures are best treated by flexing the fingers 
over a roller bandage, or a round soft palmar mass, and fixing them in 
position by adhesive tape or a roller bandage. This position relaxes 
the interossei and takes advantage of the pull of the extensor tendons 
to help correct the deformity. Molded plaster of Paris may be simi- 
larly applied by one cutting out thin strips of the wet material with 
a sharp knife and bandaging them on in any desired position. 

Fracture of the sesamoid bones of the thumb have been reported 
by Preiser^ and Morian.^ These do not tend to heal by bony union, 
and have little significance if they do not interfere with flexion. Bipar- 
tite bones must be excluded. The author has seen a roentgenogram 
of one case long after trauma in which a small fragment was detached 
and probably partly absorbed. 



1 Aertzl. Sachverst., 1907, p. 400. 

2 Zentralbl. f. Chir., 1910, p. 423. 



CHAPTER XX. 
DISLOCATIONS OF THE WRIST, HAND AND FINGERS. 

1. Dislocations of the Lower End of the Uhia. 

{a) Backward. 
(b) Forward. 

2. Dislocations of the Lower End of the Radius, Radiocarpal Dis- 
location. 

(a) Backward. 

(b) Forward. 

3. ^lediocarpal Dislocations and Fracture Dislocations. 

4. Isolated Dislocations of the Carpal Bones. 

5. Carpometacarpal Dislocations. 

6. ^Metacarpophalangeal Dislocations of the Finger and Thumb. 

7. Phalangeal Dislocations of the Thumb and Fingers. 

The luxations of the lower radio-ulnar joint are confusing and the 
literature on the subject is misleading. The Roentgen rays have fur- 
nished a modern classification which is exact. In the past many 
so-called wrist dislocations were examples of the different types of 
Colles's fracture with the varying displacements and complications. 
This is particularly true of so-called inward dislocations of the lower 
end of the ulna, which are not true dislocations but are simulated by 
the outward displacement of the lower end of the radius and the 
\\Tist in Colles's fracture. The remaining dislocations of the ulna 
backward and forward are recognized as true luxations. In 1912 
Stimson collected 22 undoubted cases of forward and 15 of backward 
dislocations of the ulna.^ 

DISLOCATIONS OF THE LOWER END OF THE ULNA. 

Backward. — The backward luxations are not common when the 
number of wTist injuries are considered. The causes are twisting 
strains which turn the hand in hyperpronation and falls on the hand 
in pronation and adduction. Children are often subjects of this 
luxation, and the condition may accompany the subluxations of the 
radial head which are caused by longitudinal traction. These sub- 
luxations in children may be complicated by wrist pain and slight 
rleformity consisting of a prominence of the lower end of the ulna 
backward (Fig. 352 j. 

Symptoms. — The hand is in some pronation and adduction, and 
there is loss of function in the ^Tist and fingers. Wrist flexion anrl 

1 Fractures and Dislocations, 1912, 7th edition, p. 747. 



538 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



extension are possible passively, but supination is restricted. The 
wrist appears narrowed, and the lower end of the ulna rides backward 
and overlaps slightly the radial margin. In recent cases the lower 
end of the ulna is abnormally movable, and its projection may be 
partly reduced by direct pressure. Differential diagnosis must exclude 




Fig. 352. — Backward dislocation of the lower end of the ulna. 

CoUes's fracture, dislocation of the semilunar, and Madelung's deform- 
ity. The position of the radial styloids, the history in the congenital 
deformity, and the roentgenogram afford a basis for distinction of 
these conditions (Fig. 353). 

Treatment. — Reduction is made by direct pressure on the projecting 
part of the ulna, usually by the surgeon's thumb, both his hands 
grasping the wrist above the deformity. He makes a strong pressure 
downward and outward to shove the ulna back into position, and 
the reduction may occur with a jerk as the lower end of the bone 




Fig. .353. — Pathological dislocation backward of the lower end of the ulna in osteomyelitis. 



slips down into its ligamentous pocket. Adduction of the hand and 
supination by an assistant favor the reduction. The hand is fixed in 
position of supination in a moulded plaster splint, kept there for four 
or five weeks, and pronation cautiously started thereafter. Fracture 
of the ulnar styloid may prevent reduction, but usually the detached 
bone fragment is pulled medially and bent around under the ulno- 



DISLOCATIOXS OF THE LOWER EXD OF THE ULNA 539 

carpal joint by ligamentous attachment. Long-standing cases have 
been reported as reduced by manipulation. One old case which 1 
saw resisted all attempts at reduction, and because the hand function 
was lessened and supination was lost excision of the lower end of the 
ulna was advised. After long-standing changes in the tissues below 
the lower end of the displaced ulna it is not possible to hollow out the 
normal cavity in which the bone lay, and reduction with open opera- 
tion becomes very difficult. If the end of the bone can be reduced, 
it tends to slip out of place again very easily and must be held by 
stitching of the ligaments foimd over it, or by a band of transplanted 
fascia applied to act as a stay. 

Results after reduction are good. Function becomes satisfactory, 
supination alone being lessened slightly. In the old traumatic cases 
which remain unreduced, more or less permanent loss of use remains. 
The hand is weakened, and a firm cicatricial mass encloses the dis- 
located end of the idna. 

Dislocations Forward. — Of this type of dislocation there are 33 
cases on record. The condition was first described by Desault, in 1791,^ 
who found the dislocation in the cadaver of an old man. 

The causes are usually direct violence which twists the wrist in 
forced supination; 7 cases were caused by this action, 1 case by forced 
pronation. A direct backward shove on the hand when the ulna is 
fixed mechanically, as in back-fire injuries in automobile cranking 
may be a cause; and muscular contractions of the triceps when the 
hand is fixed has caused 3 cases. The lesion consists of a forward and 
slightly outward displacement of the ulna after its ligamentous attach- 
ments have been torn loose. The radius may be fractured in the 
lower third,- or the ulnar styloid may be pulled off. 

Sjrmptoms. — The symptoms are loss of function in the wrist with 
varying positions of pronation and supination. The hand and radial 
side of the forearm are displaced backward from the ulna, which is 
displaced forward with some overlapping of the radius. The motions 
of the fingers are partly interfered with, and there is swelling in the 
wrist which appears narrowed, but is thickened in the anteroposterior 
diameter. The characteristic finding is the hard, round end of the 
misplaced ulna beneath the flexor tendons just above the palmar 
crease and a hollow space on the back of the wrist where the bone 
should lie. Every case must be carefully examined for possible accom- 
panying fracture of the radius.-^ 

Treatment. — Reduction is not easy to perform. The injured hand is 
grasped and traction made on it in radial flexion, while the head of the 
bone is pressed back into place by an assistant, the hand and wrist 
being turned in either extreme supination or pronation, depending 

1 .Jour, de Chir., i, No. 1, 78. 2 Darrach, Ann. of Surg., Ivi, 801. 

■Stimson. New York Med. .Jour., May 2.5, 1889; Hoist, Centralbl. f. Chir., 1889, 
Xo. 24. p. 49.5; Lewen, Centralbl. f. Chir., 1906. No. 24, p. 1128; Hoffa, Verhandl. d. 
deutsch. Gesellsch f. Chir., 1898, p. 1.50; Corntin, Gaz. hebd. des Sci. Med. fie liordeaux, 
October 8, 190.5, p. 481. 



540 DISLOCATIONS OF WRIST, HAND AND FINGERS 

on the character of the displacement. Luxation is generally reduced 
with the fracture, if there is radial fracture, and heals with it. If the 
ulna remains out of place it is the result of rupture of the triangular 
ligament, and the ulnar head becomes mobile as the joint ligament 
relaxes. A roentgenogram should be made for checking purposes 
after the reduction and the splint should be left on at least three weeks. 
If reduction cannot be accomplished the distal inch of the bone can 
be excised, as in a second case reported by Darrach.^ The patient was 
a thirty-four-year-old man whose hand had been caught in a machine 
belt a month and a half before being seen. The hand was twisted 
into extreme pronation. There was pain in the wrist, pronation and 
supination were about one-third normal, extension was normal, but 
flexion w^as limited to one-half, and the fingers were also limited in motion. 
The median and ulnar nerves showed no involvement. One-half inch 
above the palmar crease the head of the ulna could be felt in forward 
dislocation. Reduction by manipulation was impossible, and the lower 
inch of the ulna was resected subperiosteally, and after two weeks 
massage and motion were begun. After five weeks the patient resumed 
his occupation. Osteectomy is the treatment of choice in unreduced 
cases or old cases with limitation of movement and of use of the wrist. 
Cotton and Brickley^ advise that end-results are good after prompt 
reduction in fresh cases. Hitzrot^ reduced an anterior dislocation by 
flexing the wrist and turning it into full supination and radial flexion. 
After fifteen months the function was perfect, and there was no pain. 
In general the outlook is not bad because function may not be greatly 
reduced by non-reduction. 

Recurrent luxation of the ulna has been described by Cotton,^ 
who mentions 2 cases; 1 followed a Colles's fracture, and the other 
was accompanied by ulnar neuritis with a slipping out of the ulna 
on every movement of supination. An extreme laxity of the wrist 
ligaments was the probable cause, and one case was cured by oste- 
otomy, which had the effect of tightening the radio-ulnar ligaments. 

Darrach^ has also reported an habitual forward dislocation of the 
lower end of the ulna. There had been a radial and ulnar styloid 
fracture caused by an automobile-cranking accident eleven months 
before the patient was seen and a refracture within three months. 
Six months after the second fracture when the patient was thrown 
and hurt the wrist again, he felt something slip out of place at the 
ulnar head. There was a widened wrist, a silver-fork deformity, and 
decreased power. When the hand was pronated the ulnar head could 
be felt to slip back into place and the ulna was not separated laterally 
from the radial connection. 

Madelung's Deformity. — Although this work does not attempt to 
deal with congenital deformities a brief description of Madelung's 
deformity must be given to help differentiation between the traumatic 

1 Ann. of Surg., 1912, Ivi, 802. 2 Ibid., Iv, 368. 

3 Ibid., 623. ■* Dislocation and Joint Fractures, p. 364. 

6 Ann. of Surg., Ivii, 928. 



DISLOCATIOXS OF THE LOWER EXD OF THE ULNA 541 

and congenital deformities at the wrist. Dupuytren, in 1834, first 
described a condition which he called a unilateral forward dislocation 
of the ulna, and in 1878 iNIadelung^ described it as a progressive curva- 
tiu*e of the radius which developed spontaneously, and was accom- 
panied by pain and disability. Adduction and abduction of the 
wrist are not greatly limited, but extension of the wrist is. There 
is an atrophy of the carpal bones and cartilages, the epiphyses of the 
ulna and radius take on an atypical growth with an hypertrophy on 
the dorsal side, and the diaphysis of the radius is curved anteriorly 
with a dislocation backward or forward of the ulna. Most cases occur 
in adolescents of the working or the poorer classes who show evidence 
of rickets or tuberculosis. Stetten, in 1908, collected 62 cases.^ 
Females are more affected than males. Most instances have been' 
forward dislocation of the ulna, only 2 or 3 being backward. 

Pathology. — The pathology is undecided, but probably rests on a 
late rachitic deformity involving the growth of the lower radial epiphy- 
sis with a primary deviation of the articular surface forward or back- 
ward, the direction probably influenced by the repeated trauma of 
occupation. There is possibility of an unrecognized epiphyseal separa- 
tion of the radius acting as a cause. One of Stokes's cases^ might be 
interpreted as of such an origin. The patient was a fifteen-year-old 
girl who gave a history of heavy weight-lifting two years before. She 
had slight signs of rickets at the fifth costosternal junction, and both 
tibiae bowed outward. The skull was normal.^ Evidence also points 
toward the imperfection of the joint cartilages in the carpus. They 
are ossified in some areas and irregularly thickened in others. The 
epiphyseal ends of the forearm bones are not completely developed, 
and they are excurvated or club-shaped, so that they do not hold 
the carpal bones in place on the volar side. Franke^ does not consider 
the condition a true dislocation, but favors the idea that there is a 
deviation of the ^Tist axes caused by the curve in the radius. There 
are also changes in the carpal bones, which are atrophied, and there 
is relaxation of the wrist ligaments. The whole condition has been 
likened to the changes in genu valgum or scoliosis. Recently Berg,"^ 
reporting 3 cases, has made a plea for the application of the term 
carpus valgus to these wrist deformities regardless of their etiology. 

Symptoms. — The symptoms are a spontaneous and progressive 
deformity of bowing in the radius with an accompanying dislocation 
of the lower end of the ulna. There is pain and limitation of wrist 
motion, and in 2 or 3 years the deformity reaches its height, accom- 
panied by weakness, constant pain in the wrist, and restricted motion. 
There are usually signs of delayed rickets and possibly auto-intoxica- 
tion, alcoholism, syphilis, or tuberculosis (Cantas's case). When the 

' Verhandl. d. deutsch. Ges. f. Chir., vii, 259. 

* Zentralbl. f. Chir., 1908, xxxv, 949. 
3 Ann. of Surg., lii, 229. 

* Cantas, Lyon Chir., 1913, x, 434. 

5 Deutsch. Ztschr. f. Chir., 1908, xcii, 156. 

* Arch. f. Orthop. Mechanotherap. u. Unfailchir., 1913, xii, 325. 



542 DISLOCATIONS OF WRIST, HAND AND FINGERS 

diagnosis is made these various conditions must be excluded by a 
careful general examination and by roentgenogram. 

Treatment. — Many different treatments have been used in the 80 
or more cases recorded in the literature. The disease generally reaches 
a maximum deformity within three years after its inception, and 
radical treatment is not indicated except for cosmetic reasons, because 
the prognosis of functional result in adult life is good. When the 
deformity becomes stationary, surgical operation alone will effect a 
cure. Tenotomy has no value. A linear or cuneiform section of the 
radius done at the point of greatest curvature will correct the bowing 
of the bone, but this may not influence the dislocated head of the 
ulna if permanent changes have occurred about it. Function improves 
after the operation. Parkes^ has reported a case in which he sectioned 
the radius and applied a small Lane plate which was removed six 
months later after the deformity was greatly improved. Cantas 
resected 1.5 cm. of the diaphysis of the ulna 4 cm. above the styloid 
process and then straightened the radius by manual fracture and 
sutured the ulna. A plaster cast was applied for thirty days, and 
the functional result was perfect, the radiocarpal articular surface 
resuming a normal position, but the ulna did not contact with the 
carpal bones and continued to project at the wrist. Stokes believes 
that osteotomy is not indicated, but that rest and proper diet will 
gradually cause the deformity to disappear after the patient reaches 
maturity (age of twenty-five years). The silver-fork deformity per- 
sists. To obtain the best cosmetic and functional result Springer's 
advice may be taken.^ His procedure is (1) division of the pronator 
quadratus; (2) osteotomy of the radius about IJ inches above the 
joint; (3) resection of the prominent part of the end of the ulna; 
(4) complete supination of the forearm by twisting, with dorsal 
flexion and abduction of the hand; (5) a plaster cast from the middle 
arm to the finger ends with the elbow flexed. After two weeks the 
palmar half of the cast is cut oft' and massage and movements are 
commenced. 

MEDIOCARPAL DISLOCATIONS AND FRACTURE 
DISLOCATIONS. 

Carpal Dislocations. — The subject of wrist dislocations has become 
one of much interest since the roentgenogram has aided us in ex- 
plaining the intricacies of wrist displacements and the position of 
the small bones after luxation. The reader is referred to description 
of the relation of the wrist bones given previously in the discus- 
sion of fractures of the carpus. The wrist evidently is composed 
of three elements which may be concerned in fracture and disloca- 
tion. The radius and ulna, the first element, are very firmly united 
by ligaments to each other and to the second element, which is com- 

1 111. Med. Jour., 1915. 

2 Ztschr. f. orthop. Chir., xxxiii, Heft 34. 



MEDIOCARPAL AXD FRACTURE DISLOCATIONS 



543 



posed of the proximate row of carpal bones, navicular and os lunatum. 
The proximate carpal bones are in turn united to the distal row 
by ligaments which permit motion in this joint, the mediocarpal and 
the distal bones are practically immovable as units on account of 
the firm banding together by interosseous ligaments. 

Dislocations of the hand and wrist may be grouped as (1) Disloca- 
tions in the radiocarpal joint; (2) dislocations in the intercarpal 
joint between the two rows of carpal bones; (3) dislocations in the 
carpometacarpal joint. 

Mechanism of Wrist Movements and Injuries.^ — Radiocarpal disloca- 
tions are not frequent and are usually accompanied by fracture of 
one or both forearm bones. They are caused by violence, direct or 
indirect in character. Displacements are either backward or forward. 
Sievert^ has reported an instance of volar luxation of the radiocarpal 





Fig. 354 



Fig. 355 



Fig. 356 



Figs. 354. 355, and 356. — An illustration of a mechanism for intercarpal dislocations, 
adapted from Oehlecker. 

Fig. 354. — Shows a normal hand with the bone line from metacarpal, os capitatum, 
lunate and forearm bones. The radiocarpal volar ligament is indicated. 

Fig. 355. — Shows hyperextension of the hand, lunate and os magnum each contributing 
45 degrees to the angle of 90 degrees. 

Fig. 356. — Lunate luxated, held in nearly normal position by the radiocarpal ligament. 
The hand is in perilunar dorsal dislocation. 



joint from Kolliker's clinic. The lower radial and ulnar surfaces 
were fractured. The patient was a fifty-year-old man who sustained 
a fall on the back of the hand. Diagnosis was easy and reduction was 
also, but the wrist sank back into displacement immediately after 
support was removed. 

Experiments in wrist movements performed by C'odman^ in 1898 
>howed that there was no motion between the individual bones of 
the di.stal row of the carpus. Flexion and extension of the wrist occur 
entirely in the joints proximal and distal to the first row of carpal 
bones, and the variation from complete extension to complete flexion 
oi the hand, ISO degrees, is possible by movement of each of these 
joints through 90 degrees. This is illustrated in Figs. 354, 355 and ))50, 

1 Zentralbl. f. Chir., 1910, p. 1129; Miinchen. med. Wchnschr.. 1910, No. 16, p. 849. 
* Jour. Exper. Med., iii; and Bo.ston Med. and Surg. Jour., cl, No. 14, p. 371. 



544 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



which shows the probable mechanism of mediocarpal dislocations. 
It is seen that in complete extension shown here, the os lunatum and 
the OS capitatum are each rotated 45 degrees from each other's per- 
pendicular axis; the total angulation brings the axis of the os capitatum 
at 90 degrees variation from the long axis of the radius. In flexion 





Fig. 357. — Hand in hyperextension. 
Lunate and os capitatum each contribu- 
ting 45 degrees of angulation. 



Fig. 358. — Lunate slipping out, held to 
radius by radiocarpal ligament. 



the same principle applies. Codman and Chase^ called attention to 
this in 1905, and suggested that if the wrist were looked at from the 
side, in complete flexion, the axis of the lunate bone would point at 
an angle of 45 degrees to the vertical axis of the radius, and the long 
axis of the capitate bone, which formed a continuation of the meta- 





FiG, 359. — Os capitatum approaching 
radius again. Lunate squeezed out. 



Fig. 360. — Volar dislocation of the 
lunate. 



carpal axis, would add another 45 degree variation. Consequently 
the axis of the capitate bone would lie at an angle of 90 degrees with 
the radius. This axial variation in dislocation may be illustrated 
as in Figs. 357, 358, 359, and^360. 

1 Ann. of Surg., xU, 863. 



MEDIOCARPAL AXD FRACTURE DISLOCATIONS 545 

Because of their firm ligamentous attachment and their position 
protected by the styloid processes, the two proximal carpal bones 
tend to remain with the radius and idna in displacements at the wrist. 
In the discussion of fracture of the navicular and lunate bones of the 
^^Tist we haxe seen that the cause of most of the lesions Avas a fall 
on the extended hand, the resulting fracture depending largely on the 
position in ulnar and radial flexion. Violence is transmitted through 
the third metacarpal and os capitatum to the radius directly and if 
the hand is in radial flexion the navicular bone sufters fracture, the 
usual occurrence. If the hand is in ulnar flexion, the lunate bone is 
brought over into the line of compression and is damaged. The mech- 
anism of dislocation is very similar except that the hand is bent back 
in hyperextension and not held rigidly in a straight position with the 
long axis of the radius, as it is in most cases when a man falls forward 
on his hand and attempts to save him^self. With the hand in hyper- 
extension, force is applied as illustrated in Figs. 354, 355 and 356 
(from Oelilecker), and the lunate bone and os capitatum, which have 
already reached their maximal rotatory excursion of 45 degrees each, 
are called upon to take up the strain of the fall. Habitual strain or 
occupation may bring about a condition of subluxation of the carpal 
bones. Relaxed ligaments and the bone construction favor the con- 
dition. An instance of diastasis of the navicular and lunate bones has 
been reported by Layorenne.^ His patient was forced by his occupa- 
tion to use his hand in hyperextension and he developed signs of arth- 
ritis in the \YTist. A roentgenogram showed a separation between 
the navicular and lunate bone, and recovery resulted after a period 
of immobilization. Direct violence on the hand may also cause 
carpal dislocations. 

As in all joint injuries the surgeon must be on his guard against 
pathological dislocation. Destot and Japlot^ reported an injury to a 
>oung man who sustained a slight fall on the left A\Tist. There fol- 
lowed persistent pain, deformity, and swelling, although the hand had 
been immobilized at once, and ultimately a pathological subluxation 
of the second carpal row forward caused by a tuberculous condition 
was recognized. 

In Pamyan's report of 8 cases in the Canal Zone at the Ancon Hos- 
pital, the total number of admissions to the hospital in six years had 
been 120,000. In 5 of the 8 instances the left wrist was injured. 
The men employed there were all exposed to trauma. One-half the 
cases were caused by indirect violence of falls and the other half by 
direct violence of blows. Fracture of these bones does not result 
because there is not direct compression of them, but the joining liga- 
ments must take u]) the force and hold, or if they yield a dislocation 
will surely result. A point is reached in the ])ressure of hyi)erextension 
where the posterior ligaments uniting the lunate and cajjitate hones 
are stretched, where the os capitatum begins to slide backward on the 

' Soc. de Chir. de Lyon, June, 1913. ^ Ibid. 

35 



546 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



lunate, the anterior ligament between the two bones is made to bear 
most of the strain and yields, permitting the os capitatum and its 
closely bound distal row of carpal bones to be dislocated backward. 
The navicular may accompany them, especially if the hand is in ulnar 
flexion. The line of dislocation passes through its body, following the 
line of least resistance through the mediocarpal joint, a fracture of 
the navicular occurs, and the proximal fragment is displaced with the 
OS lunatum. Mouchet and Vennin^ record a case of a patient who fell 
from his horse on to his hand and was treated for nine months for a 
fracture of the radius. They found a well-marked deformity with a 
dislocation of the carpus into two parts displaced over each other. 
The navicular was fractured in the middle, one-half going with each 
row of carpal bones. Meanwhile the os lunatum (and the broken 
proximal portion of the navicular) cling closely to the radius and ulna, 
as we have previously stated, held by the strong unruptured radio- 
ulnar ligaments. The os lunatum may not rotate, but may retain a 



Os capitatum 




12 3 4 

Fig. 361.- — Lateral view of lunate dislocation adapted from VuUiet. 

normal axis line with the radius after this luxation, and this condition 
has been called per ilunar dorsal dislocation of the hand (see Fig. 356). 
When, however, the force continues and the hand is pushed farther 
dorsally, the os capitatum is hooked over behind the lunate and this 
compression drives the lunate toward the volar side and the bone is 
swung downward, usually assuming an angular position of 90 degrees 
(see Fig. 361) with the radius, being held attached to it by the radio- 
lunate ligaments. Its concave surface is directed forward. This 
state constitutes a complete volar dislocation of the lunate bone and 
is the second stage of the mechanism given above. The two condi- 
tions of the perilunar dorsal dislocation of the hand and volar disloca- 
tion of the OS lunatum are not exactly the same but differ in degree. 
In 6 cases of lunate dislocation Oehlecker^ found that 2 were volar 
dislocations and that 4 should be classed as the perilunar dorsal hand 
luxations. The volar dislocation of the lunate is likely to be accom- 



1 Rev. de Chir., 1913, p. 975. 

2 Beitr. z. klin. Chir., Bd. xciv, S. 148. 



MEDIOCARPAL AXD FRACTURE DISLOCATIONS 547 

paiiied by fractures of the radial and ulnar styloids, particularly the 
latter. Oehlecker found in all the 4 cases of perilunar dorsal dis- 
location that the edge of the os triquetrum was fractured, and that 
this fracture may lead to bone changes which we have previously 
described under fracture of the carpal bones. These small fractures 
and interference with blood supply are probably primary and lead to 
the conditions described by Preiser as typical, post traumatic osteitis 
of the lunate bone, which causes spontaneous fracture^ and the trau- 
matic malacia of the os lunatum of Kienboch.- A third and more 
advanced stage of displacement of the lunate, with or without a 
fragment of the navicular, consists in its being pushed clear under 
in an arc of 180 degrees until it lies above the end of the radius under 
the flexor tendons. The radiolunate ligament may still hold after 
this extreme rotation, or it may be ruptured. There are only 2 cases 
of this character with which I am familiar, one reported by Murphy^ 
and the other by Taaffe,^ unless the first case reported by Wallace^ 
was of the same character. The lunate and navicular fragments were 
described as having made two right-angled turns and passed beneath 
the annular ligament. 

In Volume IV of the Murphy Clinics TaafTes's case is wrongly 
ascribed to Buchanan. Taaffe's case was a dislocation of the lunate 
half an inch above the lower end of the radius in a trapeze performer 
who fell twenty feet, reduction being accomplished without anesthesia. 
Mediocarpal and lunate dislocations are not now considered rare, 
and a large number have been reported in the literature. 

Posterior dislocations of the lunate or proximal row of carpal bones 
are rare — but two or three are reported. Durand^ reported a case 
which he had previously recorded in 1907 when the patient had a 
\olar dislocation of the lunate. The bone was removed by operation. 
The second accident consisted in an injury of the other ^^Tist diagnosed 
as a sprain which was neglected for eight months. The roentgenogram 
then proved that there was a dorsal luxation up onto the capitate 
bone and a fracture of the navicular, a fragment of which accompanied 
the lunate. These two bones were removed. Goullioud, in 1910, 
reported a case of dorsal lunate dislocation reduced by manipulation. 

I am able to add a case treated this year. There was complete 
dorsal dislocation of the lunate bone after a fall on the hands from a 
height. The patient did not know how he struck the ground (see 
Fig. 364). A distinct lump appeared on the dorsum of the hand at 
the site of the lunate. Flexion and extension were interfered with 
to an extent of about 30 per cent. On the dorsum of the hand the 
extensor tendons stood out very prominently. I made unsuccessful 
attempts to reduce the bone by pressure and manipulation, but it 

» Zentralhl. f. Chir., 1010, p. 020. 

2 Ftschr. d. Roritf,'eii.str., Hd xvi, 8. 70. 

••' Clinics, .June, 1013, p. 4.31, and .June, V.n.',, p. 401. 

* British Med. .Jour., 1860, p. .308. 

' Lancet, March 22, 1013, p. 810. 

« Lyon Med., 1012, cxviii, 10-30. 



548 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



had been out of place about two months and could not be replaced. 
The lunate was removed by open operation. The radiolunar and part 
of the navicular ligaments were intact. There was rotation upward 




Fig. 362. — Dorsal dislocation of the lunate bone alone. 

of the bone about 45 degrees, the concave surface riding over the 
capitate bone. A small area of avulsion on the dorsoconcave surface 
seemed to represent the point of pulling out of the dorsal ligament 
which connected the lunate to the capitate bone (Figs. 362, 363, 364, 




Fig. 363. — Lateral view of dorsal dislocation of the lunate bone. 



and 365) . They are probably caused by falls on the hand in extreme 
flexion. A reversal of the hyperextension mechanism occurs, and the 
distal carpal bones are displaced downward and backward on the 



MEDIOCARPAL AND FRACTURE DISLOCATIONS 



549 



proximal row, the lunate (and navicular) being pushed out on the 
dorsum of the hand. Wallace in the second case reported in his 
article/ reports that the injured hand was forced back into contact 
with the dorsum of the forearm, and there remained a prominence on 
the back of the hand. The roentgenogram proved that this promi- 
nence was the capitate, hamate and pyramidalis bones forced upward 
and backward, that is, a dislocation of the second row of carpal bones 
on the first, the lunate being displaced backward also. The navicular 




Fig. 364. — Photograph of dorsal dislocation of the lunate bone. 

remained in position and preserved its usual relations with the greater 
multangular and lesser multangular bones.^ 

The usual dislocation of the wrist is the one around the lunate 
bone through the proximal joint, the perilunar dorsal hand dislocation. 
This occurs about one-fifteenth as often as navicular fracture. The 
next common variety is dislocation of the lunate accompanied by a 
part or the whole of the navicular, and rarely the triangular bone 
and pisiform remain with the two bones of the first row. Other hand 
dislocations are really those of isolated 
bones, the volar dislocation of the lunate 
leading in frequency. Eigenbrodt^ reported 
two isolated cases of lunate dislocation. 
Murphy^ in four luxations found three of 
the lunate plus fracture of the navicular 
through its weakest point and one of the 
lunate uncomplicated . Although the vari- 
ation in the type of luxation depends on 
the force of the trauma, which is probably 
greater than that producing Colles's frac- 
ture, and on the relative position of the 
hand, the structure and distribution of the 

individual bones have an influence. The development of the ligaments 
also has a bearing. 

> Lancet, March 22, 1913, p. 819. 

' DeQuervain, Monatschr. f. Unfallheilkunde, ix, 65 ; Codman and Chase, Ann. of Surg., 
xh, 863; Schoch, Beitr. z. klin. Chir., 1907-8, xci, 53; Inaug. Disser. Bern., 1907; Delbet, 
Bull, et mem. Soc. de Chir., xxxiv, 377; Hirsch, Ergenb. der Chir. u. Orthop., Bd. viii, 
753; Lillienfeld, Ztschr. f. orthop. Chir., xx, 437; Destot, Le poignet et les accidents du 
travail, Paris, 1905; Montandon, Beitr. z. klin. Chir., 1908, Bd. Ivii, Heft 1; Ebennayer, 
Fortschr. a. d. Geb. d. Rontgenstrahlen, 1908, xii, 11. 

' Bnins, Beitr., 1901, Bd. xxx. •• Clinics, iv, No. 3, 389. 




Fig. 365.— Removed dorsally 
dislocated lunate bone. Note 
the softening changes. 



550 DISLOCATIONS OF WRIST, HAND AND FINGERS 

Symptoms of Wrist and Lunate Volar Dislocations. — There is always 
a history of a fall, which the patient may be able to describe completely 
to illustrate the mechanism of the injury. When direct violence has 
caused the injury, the description is clearer, and there is no doubt 
of the direction and nature of the trauma. 

If the distal row of carpal bones has been displaced and come to 
lie posteriorly with the lunate bone rotated downward and pushed 
out of place, we naturally expect that normal movements of flexion 
and extension will be lost. Clinically this is so. The amount of motion 
contributed by the lunate in the 180 degrees between complete flexion 
and extension is lost. Consequently 90 degrees is gone and only 90 
degrees would be left, 45 degrees each for flexion and extension, or 
one-half normal. Practically, however, the os capitatum in its new 
bed cannot perform its full function in these motions, and usually a 
total motion of 50 degrees or less is all that is possible in the wrist. 
Flexion and extension are therefore greatly limited and are intolerably 
painful. In the perilunar dorsal hand dislocation there is some swelling 
and ecchymosis on the dorsum of the hand, and the sharp edge of the 
OS capitatum may be felt. Percussion test of the middle metacarpal 
is negative, and the displacement of the lunate bone is so little that 
it cannot be palpated as a separate mass in the wrist. The wrist is 
shortened, however, when measured from the radial styloid to the 
head of the middle metacarpal. A lateral view of the wrist gives an 
appearance of a Colles's fracture with a silver-fork hump, but this 
hump is located below the end of the radius, which can be palpated 
above. Radial fracture or fracture of both styloids at the wrist may 
be a complication, and rupture of the lateral wrist ligament may 
permit some freedom of motion at that joint but causes greater swelling 
and pain. 

Complete volar dislocation of the lunate is characterized by a short- 
ening of the wrist from the radial styloid to the head of the middle 
metacarpal. This dropping back of the bone may amount to 1 cm., 
and be apparent to the eye. Dorsally the proximal edge of the os 
capitatum can be distinctly palpated, and nearer the wrist is felt 
the concavity where the lunate has dropped out of place. On the 
flexor surface there is a distinct palpatory evidence of the displaced 
lunate beneath the flexor tendons. If the swelling is not great, its 
outline may be traced. In old cases the bone is distinctly outlined, 
and if the two wrists are inspected simultaneously the shortening is 
visible, and the atrophy of the forearm on the affected side is noticeable. 

In the rare and complete form of rotation of the lunate up onto 
the radius the bone can be found beneath the flexor tendons above 
the end of the radius. Crepitus elicited during the examination of the 
swelling on the flexor side or a secondary tumor mass will lead to 
diagnosis of accompanying navicular fracture. There is greater restric- 
tion of motion and more painful rigidity than in navicular fracture. 
Practically all cases occur in males, on account of occupation and 
exposure to trauma. Instances of simultaneous lunate dislocation 



MEDIOCARPAL AND FRACTURE DISLOCATIONS 551 

in both wrists have been known. Von Frisch^ from von Eiselsberg's 
cUnic reported a double isolated lunate luxation. The patient fell 
twenty feet; in the left hand there was a volar luxation and in the 
right hand a subluxation. Both bones were excised. I have had such 
a case in a laboring man aged thirty-two years (see Figs. 368 and 370). 
The lunates were each in volar dislocation, rotated 90 degrees, and the 
radial and ulnar styloids were fractured in almost identical angles, 
so similar was the effect of the trauma on both wrists. This case and 
others bear out the statement that many of these wrist dislocations 
and fractures are caused by idiosyncrasy of the patient, the mech- 
anism being much like that which causes the ordinary Colles. Before 
the Roentgen era wrist dislocations were frowned upon, and only 
specimens which were proved by dissection were accepted as bona fide. 

Pressure on the median nerve may be present in either recent or 
old cases. The disturbance may be a numbness or paresthesia in the 
distribution of the nerve, and the skin may show trophic changes in 
long-standing cases. The nails become thinned and brittle, and the 
fingers look shiny and undernourished. The hand lies in partial 
flexion and is lacking in power. Lateral movements of the wrist are 
normal, but flexion and extension are limited. The roentgenogram 
is the final method of determining the injury, and a picture should 
be made in both anterior and lateral planes, as suggested for carpal 
fractures, both wrists on the same plate, the tube pointing midway 
between them and as far forward as the level of the knuckles, accord- 
ing to Codman's method. Stereoscopic pictures of the wrist will give 
an excellent view of the bones, and when the concavity of the lunate 
is seen to be separated from the convexity of the os capitatum, luxa- 
tion is diagnosed. The types with more complete displacement and 
rotation of the lunate are easily made out by study of the lateral plate. 
The anterior plate shows the evidence of. navicular or os triquetrum 
fracture and displacement of the fragments as well as injuries of the 
kjwer ends of the forearm bones. The navicular is usually broken 
across the neck or line of the midcarpal joint which divides it into 
the portions belonging to each carpal row. Only four cases of disloca- 
tion of the whole navicular with the lunate without fracture can be 
found in the literature. They were reported by Nancrede, Hessert, 
Ely and Finsterer. Fractures of the os triquetrum are usually very 
small and involve the proximal radial surface on the volar side. 

Prognosis. — Some surgeons who have reported these cases believe 
that the prognosis varies with the treatment and that massage and 
motion may give complete restoration of function. Delbet treated 40 
cases by non-operative methods and obtained 27 bad results. On the 
whole, there are two different types of results: (1) uncomplicated 
hixations which can be reduced by manipulation give good results; 
and (2) irreducible or complicated cases treated by operation obtain 
results depending on whether the bone is reduced after opening or is 

> Wien, klin. Wchnschr., 1910, Xo. 4. 



552 DISLOCATIONS OF WRIST, HAND AND FINGERS 

excised. The best prognosis follows excision of this latter type. 
Functional results after manipulative reduction or excision by opera- 
tion are uniformly good. The cases complicated by styloid fracture 
usually result in greater restriction of wrist motions. The prognosis 
may also be partly determined on the basis of the cause. Dislocation 
caused by indirect violence which leads to fewer complications and is 
often reducible offers a better prognosis. Direct violence leads to 
accompanying fracture and also to tendon injury, which may delay the 
final result and cause restricted function. Prompt diagnosis and treat- 
ment are more important in these dislocations than in carpal fracture. 

Treatment. — Most cases do not come to the surgeon in the condition 
of fresh dislocation. A sprained wrist is often diagnosed, and the 
patient attempts to work for days or weeks until the disability compels 
surgical attention. Navicular fracture cannot be diagnosed with the 
certainty of lunate dislocation by examination alone, according to the 
symptoms outlined, and as the function of the hand in fracture is 
greater than in dislocation and immediate treatment is not so impor- 
tant, the luxations should be studied with vigor that they may be 
recognized at once. The luxations demand early treatment, as the 
remote consequences are more serious than those of carpal fractures. 

Reduction by manipulation must be first attempted in all cases, 
regardless of the character of the dislocation. The perilunar dorsal 
hand dislocations are usually easy to reduce; the volar dislocations 
of the lunate may not be. Codman and Chase, in their 12 cases, made 
a comparison of the relative value of methods of treatment and advised 
immediate reduction of the lunate luxations not complicated by 
navicular fracture. The method of reduction is as follows : 

The patient's hand and wrist are grasped in the operator's hands 
and the hand is extended with traction to reproduce somewhat the 
position of the mechanism of the cause. This position pulls the os 
capitatum away from the radius, and an assistant can then press upon 
the displaced lunate, while the hand is drawn in extreme extension. 
As the lunate slips into place the hand is again brought down into 
flexion while the traction is maintained. The maneuver may need 
several repetitions before success is attained. In the successful reduc- 
tion there is a feeling of crepitus and the deformity disappears. Like 
other dislocations the displacement becomes "old" and is irreducible 
after a period of fifteen to twenty days, although Codman and Chase 
reduced 1 case after a month with a perfect result. They reduced 
only 2 of their 12 cases by manipulation, the other 10 being operated 
on. Other uncomplicated instances of lunate dislocation have been 
successfully reduced through manipulation by Douglas,^ Vulliet,^ a 
case reported by Bazy, who reduced one a week after the luxation,^ 
and Runyan,^ who so reduced 3 out of 7 cases. One of these 7 was 

1 Ann. of Surg., Ixi, 472. 

2 Revue Med. de la Suisse Romande, Geneva, February, 1915, xxxv, No. 2, p. 58. 
^ Bull. et. mem. Soc. de Chir. de Paris, 1914, xl, 965. 

* Surg., Gynec. and Obst., 1915, p. 60. 



MEDIOCARPAL AND FRACTURE DISLOCATIONS 553 

a solitary displacement of the lunate, and 2 were complicated by 
navicular fracture. After failure of reduction by manipulation open 
operation is the procedure. Skillern^ made a manual reduction of the 
dislocated lunate, which was complicated by fracture of the navicular 
and triangular bones. The result was good after four weeks' immobili- 
zation without massage. Operative treatment may consist of open re- 
duction of the displaced bone or complete excision. Most of the German 
authors advise excision (Hirsch, Oehlecker, etc.), even before manipu- 
lation is tried. Excision is undoubtedly the choice in complete volar 
dislocation of the lunate accompanied by fracture of the navicular 
and fragment dislocation. No case of this character has ever been 
reduced by manipulation, and instances in which the lunate has been 
retiu-ned to place have not turned out well. If there is interference 
with the median nerve, or the case is of long standing with pain and 
stiffness, excision is the choice. Rarely in fresh fracture-luxation a 
replacement is made which terminates happily. Runyan's case 2, 
which had a fracture of the navicular and was reduced by manipula- 
tion, did not turn out well. Likewise his case 3 with a similar lesion, 
in which the lunate was reduced by open operation, did not result 
well. He thinks closed reduction can be accomplished in about half 
the cases, and if this method fails, open reduction should be attempted, 
excision being kept for the last step. Murphy^ is also of this opinion. 
Vulliet with 2 cases, 1 of excision, obtained best results from the 
operative removal, and the 2 cases of excision cited by Oehlecker 
gave almost perfect result, both seen after four or five years. He 
advises removal of the bone to avoid the nutritional changes which 
so often follow accompanied by grave functional loss. PooP obtained 
a fair result following excision, as the wrist motions after a year were 
full and strong except those of extreme adduction. This result was 
influenced by the change of posture of the carpal bones whereby the 
triangular was closer to the tip of the ulnar styloid, against which it 
impinged in extreme adduction. In Wallace's 3 cases he excised 
the lunate and the fractured displaced portion of the navicular when 
present, with good results but rather slow recoveries. Jaboulay^ 
reported a case of fractured and dislocated navicular and radial styloid 
with lunate dislocation. The fragments were all removed about a 
month after the accident, but a median paralysis which was sup- 
posedly caused by pressure of the navicular fragments had not 
improved much within six weeks afterward. Hitzrot^ obtained an 
excellent final result after excision of the luxated lunate in a case 
complicated by navicular and radial styloid fracture. When the 
luxation is of two weeks' standing or longer, the efforts at reduction 
are necessarily violent, and they may traumatize the joint and lead 
to permanent arthritic changes. Berard*^ recorded one case reduced 
twenty-three days after luxation which had a slow functional return 

1 Ann. of Surg., Iviii, 716. ' Clinics, iv, 411. 

» Ann. of Surg., Iv, 626. * Lyon Med., 1913, cxxi, 699. 

* Ann. of Surg., lii. 261. «Lyon Chir., 1914, xi, 101. 



554 DISLOCATIONS OF WRIST, HAND AND FINGERS 

and a swelling lasting for months. His second case was a double dis- 
location of seven months' standing which had resulted in 45 per cent, 
functional use of the hands. In the right wrist the lunate was dis- 
located forward with a fracture of the navicular, while the left wrist 
was an isolated forw^ard lunate luxation. Both lunates were excised 
with an excellent functional result and loss of symptoms of median 
nerve involvement. 

The after-treatment of all cases, whether reduced by manipulation 
or open operation and by excision, consists in wrist immobilization 
on a moulded or padded splint from the middle of the fingers to the 
elbow for from three to four weeks. Use and motion are permitted 
after that, and massage is given to return tone to the forearm muscles. 

The Technic of Operation. — A one-and-a-half inch longitudinal in- 
cision on the volar side of the palm is made, slightly to the radial 
side of the middle line. The distal end of this incision does not pro- 
ject far enough to endanger the palmar arch. The deep fascia is 
divided, and the flexor tendons are retracted without injury to their 
sheaths. The lunate is discovered and an attempt made to replace 
it. In old dislocation or in case of irreducibility the bone is excised, 
together with the fragment of the navicular, by sharp dissection of 
remaining ligamentous attachments to the radius and ulna. Liga- 
tures are rarely needed, and a deep running catgut stitch is placed in 
the fascia after the tendons have been allowed to fall back into place. 
The skin is closed, and a splint is applied. Inside of a few hours 
the patient can flex and extend the hand painlessly and to a greater 
degree than before operation. 

ISOLATED DISLOCATION OF CARPAL BONES. 

From the remarks on mediocarpal dislocation and fracture disloca- 
tion of the lunate and navicular bones, one readily understands that 
luxation of isolated carpal bones excluding the lunate, must be rare. 
The close division into two rows of carpals, their intimate anatomical 

and functional connection, and 
^..::^ the strong interosseous ligament 

r===^^^^^^^^^^~^^^'^J?^"'^^ bands preclude frequent solitary 

\ /l77 -^ \ dislocations. A large share of the 

— ~~~^"^^ Vv^5n-^"~S7 isolated dislocations are partial in 

^^^\ C^ I /f\ character, one end of the bone 
A^^^^-^\{l ^ slipping out of place. The com- 
'/ ^-^.^ plexity of the ligaments and the 

Fig. 366.— a case of ordinary volar dis- Crowded Condition of assigned 
location of the lunate alone. space in the wrist favors a recur- 

rence, and these dislocations fre- 
quently become habitual, because replacement is often incomplete, 
the infolding of torn ligament surfaces blocking reduction. Roent- 
genograms in two planes with stereoscopic pictures are needed for 
absolute diagnosis (Fig. 366). Figs. 367, 368, 369, 370, and 371 



ISOLATED DISLOCATION OF CARPAL BONES 



ODO 



illustrate the author's ease of simultaneous volar dislocation of the 
kniate bone in both wrists. 





Fig. 367. — Simultaneous dislocation of 
the lunate bones of both wrists. Note that 
the radial and ulnar styloids are fractured. 



Fjg. 368. — Lateral view of same 
wrist as the preceding figure. Note 
the radial fragments. 





Fif;. 300. — The oppcsite wrist with 
similar fracture and volar dislocation of 
the lunate. 



Fir;. 370. — Lateral view of the second 
wrist. Note that the dislocated lunate 
does not seem to cause swelling (m the 
palmar surface of the wrist. 



556 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



The Navicular Bone. — This is frequently dislocated with the lunate, 
usually only a portion of it is displaced, however, as the combination 
of navicular fracture and lunate dislocation is the usual one resulting 
from trauma exerted across the mediocarpal joint. The position of 
the navicular between the two rows of carpal bones makes it a bone 
of contention in wrist injuries. Falls with the hand in radial flexion 
cause its fracture; if hyperextention is present, fracture and dis- 
location of the proximal fragment with the lunate is the injury to be 
expected. If the hand is in ulnar flexion, as we have seen, the lunate 
becomes the centre of action, but may drag part of the fractured 
navicular into displacement. 

Luxations of the navicular bone without fracture and alone, are 
very rare. Eigenbrodt's collection contained a few cases. King, in 
1899,^ reported a case on which he operated for reduction. The 
patient was a twenty-one-year-old student who fell on hands and 
knees in the gymnasium. A small bunch seen on the anterior surface 
of the right wrist was soon lost in the general swelling. An anterior 




Fig. 371.- 



-The two lunate bones of the simultaneous double dislocation removed by 
operation. 



dislocation of the navicular alone was recognized after four weeks' 
treatment, the bone making a marked protrusion in front of the wrist 
with a deep depression behind. No flexion in the wrist was possible 
on account of position of the navicular in front of the radius. When 
the bone was cut down upon, its radial surface was found directed 
forward, having completely rotated. The adhesions were broken up' 
and the bone was slipped back into place by extension, pressure, and 
flexion, a subsequent roentgenogram verifying its correct position. 

Practically all the isolated navicular dislocations have been back- 
ward, and some have been partial. The radial styloid may be broken, 
and the extensor tendon at the base of the thumb is pressed against, 
so that unreduced cases may lead to an adhesive tenosynovitis in this 
tendon, with restriction of thumb movement. Recent navicular 
dislocations can nearly always be reduced by pressure; if backward, 
by pressure and flexion; if forward, by" pressure and extension. Old 
dislocations or partial dislocations with nerve and tendon symptoms 

1 Ann. of Surg., 1899, xxx, 213. 



ISOLATED DISLOCATION OF CARPAL BONES 557 

must be treated by open operation. The bone may be levelled off by 
a chisel after exposure or be completely removed. 

Os Lunatum. — The luxation of this bone has been discussed in the 
previous paragraphs on mediocarpal dislocation. The older literature 
on the subject is unreliable, and the recent cases verified by roentgeno- 
grams bear out the ideas of Codman, Chase, and Delbet that the luxa- 
tion of the lunate and fracture dislocation of the lunate and navicular 
fragment constitute the greater part of wrist dislocations. The vary- 
ing degrees of lunate dislocation, from the perilunar dorsal dislocation 
of the hand to positions of partial rotation of the lunate on the anterior 
radio-ulnar ligament as an axis, to complete volar dislocation of 90 
degrees and the third stage of 180 degrees rotation up on to the radius, 
are probably all caused by the same mechanism. The continuation 
of the force and its original intensity govern the relative displacement. 

Os Capitatum. — Dislocations of this bone are always backward and 
many are pathological. ^ The older cases in the literature were not 
confirmed by operation, and the first authentic case of total dis- 
location is the one seen by Stimson in 1899.^ That case was of 
nine years' standing and caused no loss of function. The roentgen- 
ogram shows a displaced os capitatum with several areas of cystic 
degeneration, the other carpal bones appearing normal in contour 
and position. Demoulin^ has reported 2 cases of dorsal luxation 
of the OS capitatum with enucleation of the lunate. They were 
both reduced under general anesthesia, and satisfactory results 
followed. The first case was Monchet's, and was a thirty-seven- 
year-old man who had suffered a back-fire injury while cranking 
an automobile. The anteroposterior diameter of the wrist was 
increased, and the soft parts were so edematous that the wrist was 
globular in shape and was locked in position. The roentgenogram 
showed a total volar dislocation of the lunate and a backward dis- 
location of the os capitatum. The second case (Mathieu) was char- 
acterized as a subtotal retrolunar dislocation of the left wrist with 
fracture of the styloid and a rotation of 90 degrees of the displaced 
lunate. Cotton reports a case in a muscular man who suffered back- 
ward displacement of the proximal end. It was reduced. 

Treatment. — Treatment of these dislocations is similar to that of 
the other ^Tist luxations. Bloodless reduction must first be tried, 
because when it is successful the resulting function seems satisfactory. 
Under general anesthesia the hand is placed in hyperextension (if 
the lunate is displaced), traction is made on the metacarpals through 
the fingers, and the concave surface of the lunate is hooked over the 
head of the os capitatum. Complete reduction is made by the press- 
ing of the OS capitatum down into position. Delbet considers that the 
hyperextension also draws out the anterior wrist ligament which has 
slid between the os capitatum and lunate. 

' .SulzlxiFger, Fortschrittc a. d. Gobietc der Roritgen.strahlen, 1901—2, p. 172. 

' Fractures and Dislocations, 7th edition, p. 770. 

« Bull, et mem. 8oc. de Chir. de Paris, 1914, N. S., xl, 965. 



558 DISLOCATIONS OF WRIST HAND, AND FINGERS 

Hamate Dislocations. — There are very few of these known. I 
find six, as follows: Buchanan/ Oberst,^ Ebermayer/ Eigenbrodt/ 
\'an Assen^ and Murphy.*^ Murphy's case offers the latest and clearest 
description. The patient, a twenty-two-year -old male, caught his 
left hand between two rollers and suffered much pain with swelling of 
the wrist and forearm. Splints and massage failed to give much relief, 
carpal fracture had been diagnosed, and after three months he had a 
restricted range of wrist motion, particularly flexion and pain on use. 
The examination showed a dorsal bony prominence located near the 
ulnar side of the hand, distinguishing it from the palmar deformities 
near the radial side of the common anterior dislocations of the lunate 
and navicular bones. This projection was also in line with the distal 
row of carpal bones, and there was a distinct shortening of the carpus 
on the ulnar side of the hand, shown by the relative proximal retraction 
of the knuckles of the little finger when the closed fists were com- 
pared. The extensor tendons of the fourth and fifth fingers were 
raised by the displaced bone. The anteroposterior roentgenogram 
showed that the hamate bone lay approximately in normal position 
but that its shadow overlapped slightly the adjacent two metacarpals 
and the os capitatum. A lateral view demonstrated the hamate lying 
dorsal to the second carpal row, and there was no fracture. The bone 
was excised through a dorsal incision to relieve the paresthesias on 
the back of the last three fingers, probably caused by pressure on the 
ulnar nerve. Van Assen's case was complicated by dislocation of the 
navicular lunate. Ebermayer's case was an open luxation which was 
left to heal. After seven months the patient refused operation and 
there was atrophy of the thenar muscles and loss of function. 

Pisiform. — A few cases of dislocation of this bone are known. They 
are caused by direct violence or muscular action, and if the tendon 
below, abductor of the little finger, and the ligaments are torn the 
bone may be drawn upward on the wrist by the flexor carpi ulnaris 
muscle. 

Cotton^ records a case occurring in a scrub girl aged twenty years, 
who slipped and struck her hand against the floor. There was tender- 
ness and a click to be elicited in the freely movable pisiform. A 
diagnosis of partial luxation was made, but immobilization gave no 
relief.^ 

Greater and Lesser Multangular Bones. — A few cases of backward 
dislocation of the lesser multangular bone have been reported. There 
is a raised deformity on the dorsum of the wrist at the base of the 
index metacarpal. Sheldon^ reported a case which could not be 

1 Philadelphia Med. and Surg. Reporter, 1881-82, xlvi, 418. 

2 Fortschr. a, d. Geb. d. Rontgenstrahlen, 1901, 1 Heft, 15. 

3 Ibid., 1908, xii, Case XVIII. " Bruns, Beitr., xxx. 
5 Zentralbl. f. Chir., 1910, p. 1129. " Clinics, iv, 423. 

' Dislocation and Joint Fractures, p. 373. 

8 Eigenbrodt, Beitr. z. klin. Chir., 1901, xxx, 805; Barois, Arch, de Med. Mil., 1891, 
Bd. xviii, 55. 

3 Am. Med. Jour. Med. Sci., January, 1901, N. S. 121, p. 85. 



CARPOMETACARPAL DISLOCATIONS 559 

reduced but which gave a good fuuctional result after several weeks. 
Sheldon's case is the second on record and occurred at the Cook County 
Hospital. It was almost exactly like Gay's/ whose patient struck a 
post in such a manner that force was borne against the metacarpal 
of the thumb and index finger, the wrist being straight. There was 
a quadrilateral swelling proximal to the metacarpal of the index and 
a bony projection of a quarter of an inch beyond the dorsal surface 
of the carpal bones. Reduction by pressure was not possible. Shel- 
don's patient, a policeman, struck a man with his fist. The right 
wrist was slightly flexed, and there was a similar swelling proximal to 
the base of the index metacarpal which was not very painful. Partial 
reduction was accomplished b}' extension of the index and pressure 
over the bone, but the deformity, projecting one-fourth inch, remained. 
This was strapped, but fifteen weeks later the deformity was still 
present. Sheldon experimented on a dozen cadavers to reproduce 
this luxation but did not succeed in doing more than fracturing the 
index finger until he freed the ligamentous attachment of the lesser 
multangular bone from the other carpal bones. He then obtained a 
simple dorsal dislocation of the bone by applying force on the distal 
end of the second metacarpal, and he concluded that the two cases 
known were probably caused by congenital weakness or absence of 
ligaments, with possible maldevelopment of the carpal bones. Only 
a few cases of dislocation of the greater multangular are on record. ^ 
The deformity lies just above the anatomical snuff box and the dis- 
locations are partial in character. They might interfere with thumb 
motions or induce tendon changes and adherence. Sulzberger^ reported 
a case. Cotton reported a case which was a complication of mediocarpal 
dislocation and was not reduced. 



CARPOMETACARPAL DISLOCATIONS. 

Luxations at the carpometacarpal joint are caused by indirect 
violence from falls or directly from blows of objects. Isolated disloca- 
tion of every metacarpal bone except that of the little finger, and also 
combinations of one or more, have been reported. The most important 
is the thumb metacarpal, which furnishes the greatest number of 
instances. Luxation of the thumb metacarpal may be backward, the 
most common; forward or outward, the two latter very rarely. The 
cause is usually a fall or blow which drives the thumb inward to the 
palm, the muscle mass of the thenar group acts as a fulcrum and the 
lower end of the metacarpal is levered outward and backward. Back- 
ward dislocation is complete or incomplete. In the complete form the 
thumb is flexed toward the palm of the hand, and the posterior edge 
of the proximal end of the metacarpal can be felt slightly displaced 

^ Boston Med. and Surg. Jour., 1869, p. 188. 

' Mosengiol, Langenbeck's Arch., Bd. xii, 723; Bonnes, Giorno Veneto, Settembre, 
186.5. 
3 Fortchr. a. d. Geb. d. Rontgenstrahlen, 1901-2, p. 172. 



560 DISLOCATIONS OF WRIST, HAND AND FINGERS 

backward at the joint, with the tense tendons passing over it. There 
is pain, swelHng, and limited motion, and the displacement may be 
reduced by pressure over the deformity. Complete dislocation pro- 
duces the same symptoms with a greater deformity, the metacarpal 
riding back on the lesser multangular bone, and the thumb appears 
shortened. Reduction is not difficult, but its maintenance is. 

Recurrent cases lead to great thickening about the joint and a 
permanent condition of subluxation. Reduction is made by traction 
outward on the thumb, with direct pressure over the displaced end of 
the bone. A permanent dressing can be made of adhesive plaster to 
hold the thumb in abduction and extension, or a small plaster cast 
embracing the thumb can be applied for two weeks. Carrette, in 
1894,1 collected 24 cases. Chancel in the same year,^ 30 cases, and Arnal, 
in 1905, added 5 more. Potherat, in 1912,^ recorded 1 case and Soubey- 
ran* added 3 more, including Regnault's^ and also Arron's €ase.^ The 
second case of Soubeyran's was reduced after being luxated three 
years, but it became redislocated a week after the cast was removed. 

A few cases of dislocation of the second metacarpal have been 
reported, perhaps ten in all. Most of these have been backward. 
Lyman^ states that Buck has collected 24 cases of dislocations of two 
or more metacarpal bones on the carpus, including all five bones and 
forms of complete and incomplete luxation. Boyer reported 16 cases, 
11 incomplete and 5 complete. Hamilton's case of the second meta- 
carpal occurred in a twenty-eight-year-old woman from a fall, and 
Humbert's case followed a kick by a horse. Lyman's case was in a 
young man who fell off a street car. His hand showed no evidence of 
trauma, but there was a prominence in the hand outline on the dorsum 
at the proximal end of the second metacarpal. The dislocation was 
easily diagnosed, but traction with pressure failed to reduce the 
deformity. An open operation showed the metacarpal completely 
overlapping the trapezoid, and a chisel placed between the two bone 
ends effectively pried them into place with a snap. There was no 
tendency to recurrence. 

There are a few other reports of isolated dislocations of the third 
and fourth metacarpals which have nothing distinctive in their descrip- 
tion. The four finger metacarpals have been dislocated at once. 
Stimson records a case in a fifteen-year-old boy who fell down an eleva- 
tor shaft. The hand was extended on the wrist and lay anteriorly 
to the plane of the forearm. There was a well-defined ridge on the 
back of the hand at the metacarpal border, and the ball of the hand 
was thickened. Reduction was made by pressure and traction but 
the dislocation recurred at once. A final healing in a satisfactory 
position with mobility of the fingers was obtained by the placing 
of the hand in a plaster dressing for three weeks. 

» Th^se de Paris. 2 Ibid. 

» Soc. de Chir., March 13, 1912. * j^ev. d'Orthop., 1912, 3 S. iii, 385. 

6 Soc. de Chir., 1912, p. 416. ^ goc. de Chir., 1912, p. 419. 

7 Ann. of Surg., xliii, 906. 



METACARPOPHALAXGEAL DISLOCATIOXS OF THUMB 561 

All five metacarpals have been dislocated. Poiilet^ reported a case 
and referred to Ericksen's- and Rivington's/ whose case was a lacerat- 
ing open injury which necessitated immediate removal of bone frag- 
ments. Ponlet's patient was thrown from a horse. There was an 
open wound with great swelling, and after fifteen days' antiseptic 
treatment a bony prominence at the line of the distal edge of the 
capitate bone was noticed. On the volar side of the hand the palmar 
crease had disappeared, and the carpal bones seemed all displaced 
backward, with a thickening of the anteroposterior diameter of the 
wrist. A partial reduction was accomplished, and after the swelling 
had subsided a fair function resulted. 

METACARPOPHALANGEAL DISLOCATIONS OF THE THUMB 
AND FINGERS. 

These dislocations are the common ones of the fingers, and the 
thumb presents many difficulties of reduction. A complete discussion 
of thumb dislocations was made by Farabeuf,^ to which the reader is 
referred for details. The head of the thumb metacarpal is enlarged 
on the palmar surface, and the articulating area is covered by smooth 
cartilage. The head projects slightly on the inner side and is held 
in place by the lateral and anterior ligaments. The anterior ligament 
is very strong and in the adult is supported by two small sesamoid 
bones (Fig. 372). Farabeuf was unable to tear off the thumb by 
traction, as surgeons had reported doing in attempts at reduction of 
dislocation, although he used a force of 150 kilograms and cut away 
the skin over the joint. 

The various muscles inserted in the thumb have an influence on 
the displacement of dislocation, particularly the flexor pollicis longus 
which lies on the inner side and is connected with the capsule of the 
metacarpophalangeal joint (see Fig. 373). The muscles in the thenar 
group are tightened when the thumb is abducted, and to produce a 
maximum relaxation of flexor pollicis brevis, abductor pollicis brevis, 
and adductor pollicis transversus, the thumb must be adducted into 
the palm with the hand held straight out on the wrist and in slight 
abduction. 

Types of thumb dislocations at the metacarpophalangeal joint are 
as follows: 

d) Posterior dislocation, the usual form which is complete or 
incomplete. 

(2) Anterior dislocation. 

(Z) Lateral dislocation, which may complicate the first two. 

Posterior Dislocation. — Posterior dislocation is caused by hyper- 
extension of the thumb from })Iows on the distal phalanx, as in striking 

1 Bull, et Mem. de la Soc. de Chir. de Paris, x, 902. 

2 Science and Art of Surg., London, 1864, 4th edition, p. 313. 
' Lancet, i, 270. 

* Bull, et Mem. de la Soc. de Chir. de Paris, 1870, ii, 21. 
36 



562 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



against a baseball. The phalanx is luxated backward on the meta- 
carpal, and the anterior ligament is ruptured across, accompanying 
the phalanx in the displacement. 

Complete Form. — The thumb phalanges assume either of two posi- 
tions (Fig. 374). In the first position they stand erect, the articular 
surface of the phalanx rides on the dorsum of the metacarpal, and the 
rounded head of the metacarpal lies forward, thrust through the rent 
in the capsule. The lateral ligaments are also torn, and the attached 




Fig. 372. — Roentgenogram of hand, showing the usual sesamoids to be found, 
particularly those of the thumb. 



Note 



muscles hold the distal portion of the thumb in the erect position, 
the flexor longus pollicis being stretched over the head of the meta- 
carpal or lying at one side. The sesamoids may separate, one going 
to either side of the metacarpal head, or in the complex form described 
by Farabeuf they may adhere closely to the torn capsule and be 
carried up between the metacarpal and phalanx. He believed that 
the sesamoids caused much of the difficulty in reduction (Figs. 375 
and 376). 



METACARPOPHALANGEAL DISLOCATIONS OF THUMB 



563 



In the second position, the distal portion of the thumb, instead of 
remaining erect, held by the short muscles, has been manipulated or 
pushed by the force until it has been placed further backward and 




Fio. 373. — Muscles of the left hand. Palmar surface. (Gray.) 



5G4 



DISLOCATIONS OF WRIST, HAND AND FINGERS 



brought down into a line parallel with the metacarpal without reduc- 
tions being accomplished (Fig. 377). The capsule (and occasionally 
the sesamoids) lies between the bone ends and 
causes obstruction to reduction, the muscles 
exerting less influence. 

Incoviplete Form. — The capsular tear and 
the trauma are not so great, and the phalanx 
has not been luxated completely away from 
the metacarpal head. It lies in part contact 
against its posterior surface, h^ld by the re- 
maining intact portion of the capsule and the 
stretched muscles (Figs. 378 and 379). The 
incomplete form may become an habitual 
subluxation from repeated traumatism, and 
some persons can luxate and replace the joint 
at will by muscular action. The thumb does 
not stand so erect as in the complete form, 
and the head of the metacarpal is not so 
prominently palpable, nor is the distal portion 
of the thumb as mobile laterally as in complete 
dislocation. 

Treatment." — Nearly all fresh posterior dis- 
locations are reducible by manipulation. The 
short muscles of the thenar group must be 
relaxed before the luxation can be reduced, and, 
as we have previously seen, this is accomplished 
by a position of the hand in a straight line 
with the forearm, with slight abduction and adduction of the thumb 
toward the palm. The metacarpal is also pressed in toward the 




Fig. 374. — Complete 
posterior dislocation of the 
thumb; phalanges erect. 




Fig. 37.5. — Simple complete dislocation; outer side, (Farabeuf.) 



palm to aid in the muscular relaxation. The manipulation proceeds 
by hyperextension of the thumb. As the muscles relax, the phalanx 



METACARPOPHALAXGEAL DISLOCATIONS OF THUMB 565 

in a h\']:>erextended pc^sition is worked down over the head of the 
metacarpal by being pnshed and rocked nntil it is felt to slide over 




Fig. 376. — Simple complete dislocation. (Farabeuf.) 




Fig. 377. — Complex dislocation. (Farabeuf.) 




Fig. 378. — Incomplete dislocation of the thumb. (Stimson.) 




Fig. 379. — Incomplote dislocation. fFaral>euf.) 



566 DISLOCATIONS OF WRIST, HAND AND FINGERS 

into normal position, after which the distal portion of the thumb is 
flexed and the replacement is finished. There is little tendency to 
recurrence. The thumb is dressed in a position of slight flexion by 
either a plaster splint or a small cast, or most often by being strapped 
with adhesive plaster close into the palm. Ten days in this position 
permits a healing of the torn ligaments, and use is then begun. 

Capsular interposition with aid of the sesamoids may prevent 
reduction, and arthrotomy is then indicated. A longitudinal incision 
over the lateral palmar surface of the prominent metacarpal head is 
made. If the head extends out through a buttonhole in the capsule, 
this is enlarged, and reduction is made under sight by the manipula- 
tion suggested previously. Obstruction by the interposition of capsule 
and sesamoids requires a larger exposure; the thumb is hyperextended 
and the obstruction is overcome by drawing with a force on the distal 
end until the reduction can be accomplished. 

A stiffened or enlarged joint may result from any kind of reduction. 
A prolonged immobilization after reduction favors a better function- 
ating joint. With arthrotomy there are now no failures of reduction. 
Many of the cases formerly reported unreduced obtained some function 
even in the presence of deformity and limited motion. 

Anterior Dislocations. — ^Anterior dislocations are very rare. They 
are caused by falls or blows which drive the thumb inward while in a 
position of hyperextension or hyperflexion. The phalanx is displaced 
in front of the end of the metacarpal, which rides on the dorsum of 
the phalanx. The capsule is usually torn on the posterior and lateral 
aspects, and the flexor tendons are stretched over the metacarpal 
head or are displaced laterally. There has usually been noted some 
rotation with this anterior dislocation. 

Treatment. — ^Treatment is not difl&cult; reduction usually follows 
traction on the thumb, accompanied by flexion and compression on 
the phalanx backward. Arthrotomy is performed for recurring cases 
to strengthen the capsule, or for irreducible luxation. 

Lateral Dislocations. — ^Lateral dislocations have been reported, and 
some lateral displacement often accompanies the two other forms. 
Lateral luxation can be replaced by traction and direct pressure. 

METACARPOPHALANGEAL DISLOCATIONS OF THE FINGERS. 

Phalangeal Dislocations of All Five Fingers.-— The metacarpo- 
phalangeal joints of the fingers are similar in anatomical structure to 
the thumb-joint, and the anterior capsular ligament is the strongest. 
The index and little fingers are often supported at this joint by sesa- 
moids (see Fig. 372). 

Posterior dislocations predominate over all other types, and the 
total dislocations of all fingers do not equal the number involving the 
thumb alone. Hyperflexion from direct or indirect violence bends 
the finger back until the anterior capsule is torn across near the meta- 
carpal insertion, permitting the finger to be displaced backward, as 



METACARPOPHALANGEAL DISLOCATIONS OF FINGERS 567 

in thumb luxations. The hixation may be complete or incomplete, 
more often the former, and is frequently complicated by fracture of 
the metacarpal near the hand. Interposition of capsule and sesamoid 
bones has been noted in these dislocations also, and the main obstacle 
to reduction is the infolding of the capsule over the end of the phalanx. 

Shortening and rigidity of the affected finger in a position of flexion 
are noticeable. The phalanx is pushed back so that the knuckle is 
deformed by a hump on the back of the hand, and the head of the 
metacarpal can be felt in the palm. A partially erect position of the 
finger is possible when the displacement is great, and the attached 
tendons hold the finger firmly against the metacarpal, all the joint 
ligaments being torn. Amandrut^ recorded a case of complete back- 
ward dislocation of the metacarpophalangeal joint of the left middle 
finger in a boy aged eleven and a half years. There was also a fracture 
of the ulna just above its lower end and a separation of the radial 
styloid. Reduction attempted by hyperextension and traction on 
the finger failed. A pointed tenotome was then inserted on the dorsal 
aspect of the hand near the head of the metacarpal and at the outer 
side of the extensor tendon of the finger. All the interposing soft 
parts do'^Ti to the articular surface were divided and the finger was 
guided into position by traction and manipulation. 

Treatment. — Reduction of incomplete luxation is not diflficult. The 
patient will often reduce by making traction himself on the distal end 
of the finger to pull the joint into place. Cases coming to the surgeon 
are treated by traction and flexion, when the phalanx slips over the 
metacarpal. Complete luxation is often difficult to reduce. The 
method used for thumb dislocations should be used, namely, the 
finger should be forced into hyperextension and then the phalanx 
should be pushed down over the metacarpal, being rocked to force 
the torn capsule out of the way. Old cases and irreducible ones, 
especially those complicated by fracture of the metacarpal, will need 
arthrotomy for reduction. An incision over the palmar aspect of the 
metacarpal head reveals the joint after the tendons are retracted, and 
the bone can be pried into position, the interposing capsule being 
lifted out of the way. Complicating fracture increases the difficulty 
of reduction, and I have never been able to reduce complete posterior 
luxation in the presence of fracture without an open operation. 

Peraire- reported a bloody reduction of a backward dislocation of 
the little finger. He found that the sesamoid on the flexor tendon 
obstructed reduction, and after cutting the glenoid ligament, he was 
able to pry the two bones into position. Ozenne, discussing the report, 
inquired why Farabeuf's method of hyperextension and shoving reduc- 
tion had not been tried. 

Forward dislocations of the metacarpophalangeal joint are infre- 
quent. The deformity is reversed: a projection exists forward in the 
palm of the proximal end of the phalanx, and a prominence of the 

1 Rev. d'Orthop., 1912, 3 S., iii, 95. « Paris Chir., 1911, iii, 817. 



56S DISLOCATIONS OF WRIST, HAND AND FINGERS 

metacarj)al head on the dorsum. The fingers may be shghtly extended, 
with flexion of the two distal phalanges. Reduction is made by trac- 
tion, pressure against the base of the phalanx, and flexion. 

Dislocations at the Second Phalangeal Joint.^These luxations 
may be backward, forward and lateral in combinations. Backward 
luxation is the most common and is caused by direct or indirect 
violence. Capsular tear and the pull of the muscles determine the 
position of the distal bone, which may be partially erect or may lie 
prominently displaced backward in the same longitudinal axis as the 
second phalanx. Delaunay^ reported a posterior external luxation of 
the ring finger in a woman aged thirty-six years, caused by its being 
caught in a wire of a machine. The second phalanx made an obtuse 
angle of 110 to 120 degrees with the first phalanx and was deviated 
inward so that the terminal phalanx lay across the palmar surface of 
the middle finger. 

Reduction is made by traction and direct pressure on the phalanx. 
If the flexor tendon interferes with replacement, the distal phalanx 
may be rotated and shoved into place. 

Forward luxation of the middle phalanx is characterized by displace- 
ment of the base of the phalanx upward on the palmar surface of the 
proximal phalanx, which assumes a correspondingly prominent posi- 
tion on the dorsum of the finger. There may be some lateral devia- 
tion, as in a case of Delaunay's.^ A forty-eight-year-old man fell from 
a carriage and caused an antero-external dislocation of the second 
phalanx of the index finger. There was no fracture, and reduction 
was made by traction in the long axis. The combination of anterior 
and lateral luxation was probably caused by a rupture of the flexor 
tendon after the anterior luxation occurred. Reduction is generally 
simple by direct traction and pressure. 

Lateral dislocations are rare. There are not more than nine or 
ten cases on record, and Delaunay disputes Rollet's case of external 
luxation at the second phalanx. Many of the lateral displacements 
are partial, and there are open wounds, the position of the bones being 
determined by the extensive laceration of the soft parts. There is 
some shortening, an angular deformity, and a position of flexion of 
the distal portion of the finger. Replacement is obtained by traction 
and pressure. 

Luxation of the distal phalanges are similar to those of the second 
phalanx and may be backward, forward, or lateral. The backward 
dislocations are the usual type (see Fig. 380), anterior dislocations 
having been found in the thumb alone. They are caused by direct 
blows or falls on the fingers. As in the other finger joints, the anterior 
ligament which is the strongest, is subjected to a breaking strain and 
the distal phalanx slides back over the second , assuming any position 
between hyperextension and flexion. The injury may cause an open 
wound. 

1 Paris Chir., 1912, iv, 18. 2 ibid., 1911, iii, 842. 



METACARPOPHALAXGEAL DISLOCATIONS OF FINGERS 569 

Reduction is not easily accomplished, because there is so little of 
the distal phalanx to grasp in making traction, and the pull of the 
flexor tendon is hard to overcome. About one-quarter of the reported 
cases have failed to yield to manipulative methods of reduction. 
Arthrotomy is indicated if the bone cannot be shoved back after 
traction fails. The proximal portion of the thumb or finger is grasped 
in the operator's two hands and the luxated bone is pushed into place 
with his thumbs. By open operation the lateral ligaments can be 




Fig. 380. — Backward dislocation of distal phalanx. 



severed and the capsule or flexor tendon can be pulled out of the 
Bilhaut^ reported a case of backward dislocation of the distal 



wav 



phalanx of the thumb which resisted manipulative efforts even after 
the injection of cocain about the joint. The patient was given chloro- 
form, and through a lateral external incision over the joint the lateral 
ligament was cut and a reduction obtained. The capsule was sutured 
and a primary union resulted. 



1 Ann. de Chir. et d'Orthop., Paris, 1911, xxiv, 321. 



CHAPTER XXI. 

FRACTURES AND DISLOCATIONS OF THE PELVIS. 

Fractures and dislocations of the true pelvis, including the ring 
of the pelvis, the ilium, ischium, pubis, the acetabulum, sacrum and 
coccyx. Fractures and dislocations of alee of the ilium. 




Aperture of commumcatu 

with 
bursa under Psoas and 
ll'.acus 



Fig, 



381. — Articulations of pelvis and hip. Anterior view. (Gray.) 



From a structural standpoint the pelvis is a wonderful combination 
of arches and counter-arches built to sustain body weight and to resist 
shocks, and to protect and support viscera and genital organs. It 
possesses great strength in both the perpendicular and lateral diam- 
eters and a definite degree of elasticity. Two main arches have 
been described by Morris.^ The first, or femorosacral, from the sides 
of the sacrum to the acetabulum, transmits the body weight to the 



1 Anat. of Joints of Man. 



FREQUENCY 



571 



femoral heads and down the legs. This is strengthened by a secondary 
arch composed of the rami and bodies of the pubic bones which resists 
spreading. The second main arch is the ischiosacral, which transmits 
the body weight to the tuberosities of the ischium. This is also sup- 
ported by a secondary arch, formed by the rami of the ischii and pubic 
bones. There are in addition, lateral and anteroposterior arches to 
resist strains in those directions. The pelvic ligaments are also very 
strong and so situated and crossed that they increase the resistance 
of the bony pelvis to stresses (see Fig. 381). The three bones com- 
prising the pelvis, ilium, pubis and ischium unite about the acetabulum 

Ev eiqU centres ^ ^^''^^ privmry {Ilium, Ischium, and Pubis) 
^ ^ \ Five secondary 



C^e^ 




Fig. .382. — Plan of ossification of the hip bone. The three primary centres unite 
Through a Y-shaped piece about puberty. Epiphyses appear about puberty, and unite 
about twenty-fifth year. (Gray.) 



to form that cavity. The centres of ossificationunite as described in 
Fig. 382. 

Frequency. — Bruns states that fractures of the pelvis equal about 
0.3 per cent, of all fractures. When both the true pelvis or ring frac- 
tures and the false pelvis fractures of the ilium are counted, this 
percentage is raised. Many are never diagnosed. Some patients die 
of other injuries, and the pelvis fracture is not enumerated. In the 
series of 11,302 fractures investigated at the Cook County Hospital, 
pelvic fractures were found 76 times in the eight-year period embraced 
in those figures. This is equivalent to 0.67 per cent. In 1914 there 



572 



FRACTURES AND DISLOCATIONS OF THE PELVIS 



were 12 pelvic fractures, 6 of the pubic bone, 3 of which were of both 
rami, 4 of the iHum, 1 being of both sides simultaneously; 1 of the 
pelvic ring in several places, and 1 of the ischium accompanied by a 
break in the pubic ramus. Out of 12 fractures there was but one 
death, that being the case of the multiple fractures of the pelvic ring. 
The usual cause of these injuries is direct violence, which must be 
severe, because the bones give way only to great force. Indirect 
violence may be a cause when the force is transmitted through the 
ischium by falls in a sitting posture, or transmitted through the 
acetabulum from the legs in falls on the feet. The direct violence 
of squeezing between the old-fashioned bumpers and hand couplings 
of railroad cars was a frequent cause. Crushing injuries of the pelvis 
caused by falling earth or timbers, or slides of caved-in excavations, 
or by the patient rolling between a fixed and movable body, such as 




Fig. 383. — Fracture of the inferior pubic ramus with little displacement. Seen from 

behind. 

a boat and a pier or a railroad car and a platform, are found. The 
trauma may act from several directions, and there are consequently 
any number of displacements. 

Pathology. — In anteroposterior crushing the pubic rami on one or 
both sides generally break first, and if the separation is not great and 
the trauma ceases, no important displacement occurs (Figs. 383 and 
384). If the force continues, the wings of the pelvis are spread apart, 
and the sacro-iliac joints are either dislocated through a giving way 
of the ligaments, or if they hold, suffer a fracture near the articulation 
(Fig. 385). Owen^ recorded a case in a woman aged thirty-nine years 
who attempted suicide by jumping from a window. The pelvic rami 
on both sides were fractured, the left sacro-iliac synchondrosis was 



Kentucky Med. Jour., xii, No. 12, p. 378. 



PATHOLOGY 



57[ 



separated, the labia were lacerated, and yet the bladder and urethra 
were intact. 




Fig. 384. — Fracture of the inferior pubic ramus. 




Fig. 38.5. — Severe trauma causing separation of the symphysis. Pubic fracture of one 
pubic ramus and fracture through the ilium near the sacro-iliac articulation. 



574 



FRACTURES AND DISLOCATIONS OF THE PELVIS 



Double vertical fracture of the pelvis was described by Malgaigne, 
This is caused by force received on the greater trochanter of the femur, 
the side of the pelvis or the leg, transmitted upward. The acetabulum 
may be cracked, but the two lines of fracture are commonly one in 
front in the pubis and the other in the rear through the ilium, pos- 
terior to the acetabulum. This lateral fragment may be pushed 
upward and dislocated out of position (Fig. 386) . For fractures of the 
acetabulum see paragraph dealing therewith. 

Malgaigne's fracture may involve the sacrum itself, running diagon- 
ally through the sacro-iliac joint in part. This may be caused by a 
falling and striking on one side of the pelvis and the ischium at the 




Fig. 386. — Malgaigne type of double vertical pelvic fracture in a child, 
portion of the pelvis is pushed up out of place. 



The lateral 



same time, as the fracture is rarely bilateral. If the broken-out area 
is displaced upward, or laterally, the leg and hip motion on that side 
are limited, there is apparent but no real shortening, and palpation 
can usually discover the displacement. The broadening of the front 
or the narrowing of the rear of the pelvis may be seen at first glance. 

Displacement is not often great, and the severity of the injury does 
not depend on the amount of displacement so much as on the site of 
fracture. It must also be understood that displacement found after 
accident may represent only a small portion of the displacement at 
the exact moment of injury, because the pelvis may have sprung back 
into shape. Within the last year at the Cook County Hospital I saw 



PATHOLOGY 575 

a double vertical fracture in which the leg on the affected side had 
tliree inches apparent shortening, arising from the great upward dis- 
placement of the whole side of the pelvis. The patient had no symp- 
toms of complications except a little obturator nerve pain down the 
inner side of one thigh, and after a week's rest on a modified Bradford 
frame he became so irked by the confinement that he demanded 
crutches and walked home. Other cases with little palpable displace- 
ment have ended fatally from severe complications, especially those 
which involve the bladder and urethra. Anteroposterior compression 
and fracture are likely to injure the bladder and lateral force to injure 
the urethra.^ When the pubes are violently separated, the urethra is 
torn across at its ligamentous attachment, and an extravasation of 
blood and urine follows in the scrotum and perineum. The space 
of Retzius is invaded in extraperitoneal rupture of the bladder. Blood 
and urine point upward, following the fascial planes, to show in the 
inguinal region as ecch^Tnoses or soggy edema. The rough edge of 
bone, after the pubic separation, may rupture the iliac vessels. Gerster^ 
reported a case which showed laceration of the common iliac artery. 
He also cited a case of left-sided pelvic fracture in a female which 
did not result in direct injury of the urethra, but which caused com- 
pression of the urethra by a blood-clot so that the catheter had to be 
used for sixteen days. 

Bladder injury may consist in a contusion and hemorrhagic infil- 
tration of the wall or complete rupture, which is either intra- or 
extraperitoneal. Extraperitoneal rupture usually involves Retzius's 
space, and the retroperitoneal area. Intraperitoneal or intra-abdominal 
rupture is also found, especially when the bladder is full at the time 
of accident and is deprived of its bony protection by the pubis. The 
tear in the bladder is often transverse and the mucous membrane 
may pout out of the wound into the abdomen. I have seen such a 
tear four inches long. Rarely the wound instead of being clear cut is 
lacerated and jagged. 

Urine and blood extravasations become quickly infected, even 
when drained. Necrosis of the tissues develops. After urethral 
rupture rarely a localized abscess in the perineum forms. 

The psoas muscle spreads out over the ilium and may be trauma- 
tized and contused. Bone fragments may penetrate it or a hematoma 
form in its body. These cause pain when the leg on that side is raised 
and may be a valuable sign in diagnosing obscure fractures. 

There are severe complications in some cases and in addition to 
the signs of fracture of the pelvis there is often evidence of shock. 
Complications involving the urethra are manifested by marked desire 
to urinate with no results; a catheter passed into the bladder may 
fail to reach the cavity, if the laceration is at the base, and a few drops 
of bloody urine alone will be evacuated. If the bladder cavity is 
entered, there may be a few ounces of bloody urine withdrawn. It is 

* Sherman, Ann. of Surg.» lii, 143. 2 Ann. of Surg., lii. 



5/0 



FRACTURES AND DISLOCATIONS OF THE PELVIS 



also possible for the catheter to pass through the bladder rent and 
enter the free abdominal cavity. Little or no urine is obtained; 
abdominal symptoms of pain, distention, and increasing flank dulness 
are evident. 

The rectum or sigmoid may be ruptured. An extravasation of 
fecal material into the perirectal tissues and perineum, or into the 
abdomen, results with inflammatory symptoms, and there is a bloody 
stool or evidence of blood found in the rectum by the tube. Nerve 
injury of the sacral plexus is rare, unless there is severe crushing 
injury of the sacrum. Traumatic hemorrhages, rupture, and ileus in 
the bowel are complications to be feared after severe crushes. Louns- 
bury^ reports an interesting case which died on the ninth day. 

Separation of the symphysis pubis occurs in child labor and also 
in traumatic cases. In the latter class the separation may be very 




Fig. 387. — Wide separation of the symphysis pubis accompanied by fracture of the 

pubic rami, 

great or simply a slight starting. Falls and severe strains, as horse- 
back riding and forcible separations of the thighs, are the cause (see 
Fig. 387). They may be accompanied by fracture or separation of 
the sacro-iliac joints, but visceral complications are less frequent than 
in fracture of the rami. A palpable gap is present except in cases of 
little separation, and there is local pain and tenderness on pressure. 
Walking, and pressure on the pelvic brims, are also painful. The 
separation may be between cartilage and bone or right through the 
cartilage, giving a ragged faint shadow in the roentgenogram. The 
prognosis depends on the visceral and bone complications, many 
cases leading to fatal termination. Other combinations of fracture 
and dislocation involve the pubic rami and symphysis, the sacro-iliac 

1 Railway Surg. Jour., 1914, p. 9. • 



SYMPTOMS AND DIAGNOSIS 



577 



joints, and the displacement of the sacrum. These are all caused by 
extreme violence and are of little interest clinically, as death usually 
follows in a few hours in spite of any treatment (Fig. 388) . 




Fig. 388. — Fracture of the pubic bone near the symphysis caused by direct violence. 

Symptoms and Diagnosis. — Pain, localized at the points of fracture, 
or ^Yhen the pelvic girdle is compressed between the two hands or 
rocked up and down is an important symptom. Crepitus is thus 
demonstrated in a small proportion of cases, or is felt by the patient 
when he is turned over. Ecchymotic spots in the groin and perineum 
and edema of extra vasated fluids are helpful findings (Fig. 389). 




Fig. 389. — Fracture of the pubic rami with fracture of the head of the femur. 



Walking may be possible but painful and accompanied by muscle spasm 
in the legs and thighs. If the displacement is noticeable, there may 
be apparent leg shortening or palpable changes in the pubic contour. 
37 



578 FRACTURES AND DISLOCATIONS OF THE PELVIS 

Symptoms of the complications depend on the abdominal, urinary 
and rectal findings. Rapidly increasing dulness in the flanks or lower 
abdomen within the first twelve hours after injury indicates intra- 
peritoneal rupture of the bladder and peritonitis. Hemorrhage is 
differentiated by signs of greater shock. Perineal and scrotal swelling 
of urinary extravasation which follow injury of the bulbous portion 
of the urethra takes twelve to eighteen hours to develop. Extravasa- 
tion of blood and urine into the groins and pubic regions indicates 
extraperitoneal rupture of the bladder or urethral injury back of the 
triangular ligament. The time of onset of this sign depends on the 
amount of urine in the bladder at the time of accident, but it is usually 
slower than the perineal swelling. 

When the sacro-iliac joint is displaced, the posterior iliac spine is 
raised or depressed and may be dislocated laterally compared to the 
opposite side. In the double vertical fracture, if the broken-out piece 
is widely dislocated, it may be movable by direct manipulation or by 
traction on the leg. Sometimes it is so securely impacted that no 
ordinary force will move it, and it should be left in situ unless there 
are nerve pressure symptoms. These conditions of fracture and dis- 
location must be differentiated from simple sacro-iliac strain or possibly 
traumatic sciatic-nerve injury or tuberculosis of the sacro-iliac synchon- 
drosis. If the pubis is held fixed and there is freedom of motion and 
lack of muscle spasm in the back, tuberculous conditions in the spine 
and hip can be eliminated. Sacro-iliac strain usually gives localized 
soreness over the joint involved, which is promptly relieved by snug 
binding. The roentgenogram is also very helpful in deciding displace- 
ments and possible fractures after falls. 

Course and Prognosis. — ^These depend largely on the complications. 
As previously stated, in 12 cases at the Cook County Hospital, in 
1914, there was but 1 death, that in a severe multiple fracture. The 
simple fractures of one ramus, or of parts of the false pelvis, tend to 
heal quickly, generally with some deformity. Complicated cases 
with visceral lesions have a mortality of about 50 per cent., and the 
immediate prognosis depends on the character of these complica- 
tions and the promptness of treatment. Eight cases were reported 
by Sabin;^ 2 complicated cases died, and the 6 others recovered, 
although 2 were accompanied by urethral damage, 1 by abscess, and 1 
by bladder rupture. The iliac crest was injured in 2 cases. 

Treatment. — Treatment depends on the character of the fracture 
and displacement and the complications. Simple cases with no 
complications may be reduced by gentle manipulation or traction 
on a leg. I have never been able to perform this manipulation suc- 
cessfully but once. If much force or mechanical extension is necessary 
to make reduction, the deformity should not be interfered with. The 
patient should be put at rest in bed or on a Bradford frame with the 
canvas raised just above the mattress. A firm swathe or adhesive- 

1 Northwest Med., 1914, M. S., vi, 159. 



TREATMENT 579 

plaster binding can be applied from trochanter to trochanter. This 
often increases rather than diminishes the pain in the early hours 
after injm-y, more relief coming from the Bradford frame. Buck's 
extension may be applied to both legs and the head of the frame 
lowered. Open fractures are treated as directed in the chapter cov- 
ering them; as a rule the injuries are so severe that attention is 
directed immediately to the complications. 

It is wise to have the patient urinate as soon after pelvic injury as 
he is seen, or if he is unable to do so, a catheter should be used to 
determine the condition of the urethra and bladder. If a small amount 
of bloody fluid is obtained before the bladder is reached, the urethra 
is torn across or lacerated. When the urine is returned bloody and in 
small amounts, rupture of the bladder is suspected. Under no circum- 
stances do I believe it wise to introduce a measured amount of sterile 
fluid to ascertain when proportion can be returned by the catheter. 
False information may be obtained, or increased danger of peritonitis 
from the rupture and bladder may follow. For similar reasons enemata 
should not be given even when the rectum is not suspected of injury. 
When bladder or urethral ruptures are seriously suspected, operation 
should be done at once. Probably less than one-half of 1 per cent, of 
bladder ruptures recover spontaneously. If there is urethral rupture, 
and perineal extravasation is manifested, free opening by perineal 
section should be made and drainage from the bladder provided for 
by a catheter inserted in the proximal urethral opening, if it can be 
found, or by free incision into the bladder. Rubber strips must drain 
the perivesical space. A catheter may be introduced into the whole 
length of the urethra when bladder drainage is provided for, with a 
view to early healing and restoration of urethral continuity. Some 
authors advise immediate suture of the torn urethral ends when they 
are exposed in the perineal section. The cases are rare in which 
this can be done, and it is as good practice in deep ruptures to be 
sure of bladder and tissue drainage, depending on later operation 
after recovery for attention to the urethra. More distal tears or 
partial ruptures through the urethral wall are sutured successfully. 

Free fluid in the abdomen, shock, and lack of urine call for supra- 
pubic operation. If the bladder is ruptured, it must be closed by a 
double row of sutures, and drainage from the peritoneal cavity must 
be provided. Torn vessels, nerves, and other abdominal lesions are 
cared for in accordance with general surgical principles. 

Traumatic lesions of the sacro-iliac joint alone are frequently met 
with. These can be divided into (1) sprains, (2) relaxations or sub- 
luxations and (3) true dislocations. The sprains are temporary in 
character, occurring mostly in women during pregnancy or menstrua- 
tion, in positions of extreme flexion, or following attempts to lift heavy 
weights. Men sustain sprains from falls or slight crushing accidents. 
They are diagnosed by the local pain and tenderness, pain referred 
to the point where the pelvis is jarred or compressed, the negative 
roentgenogram, and the therapeutic test of strapping which gives relief. 



580 FRACTURES AND DISLOCATIONS OF THE PELVIS 

Subluxations and true dislocations are caused by direct or indirect 
violence. Roberts^ described a case in a twenty-one-year-old man 
who was crushed in a car accident. There was pain in the back, hip, 
and epigastrium. A roentgenogram showed a subluxation which 
was reduced under anesthesia. There was no feeling of crepitus, but 
the reduction was accompanied by a sensation like that imparted by 
the return of a ball-and-socket joint. Two similar cases were reported 
by Ashhurst at the same time. The legs show an equal length and 
thus rule out hip-joint injury. 

The treatment is rest and strapping after reduction. In severe 
cases of "sciatic scoliosis" where the nerve pain is due to the sub- 
luxation, it is better to use a plaster spica after reduction. Other 
references: Chapman^ and McClure.^ 

A case of dislocation of the ilium with separation of the symphysis 
pubis was reported by Young.^ The accident was caused by the 
patient leaning forward and lifting a heavy piece of timber. After 
six months, a fifteen-pound weight applied for ten days was of no 
effect, and as the Roentgen picture showed the condition, anesthesia 
was given and a reduction made by traction. A subsequent picture 
demonstrated a restoration to normal. 



FRACTURES OF THE ACETABULUM, INCLUDING CENTRAL 

(INTRAPELVIC) DISLOCATIONS OF THE HEAD OF 

THE FEMUR. 

These fractures are divided into : 

(1) Fractures of the rim of the acetabulum. 

(2) Radiating fracture of the acetabulum, including fracture of 
the floor and epiphyseal separation. 

(3) Penetrating fractures with or without intrapelvic displacement 
of the head of the femur. 

Fractures of the Rim of the Acetabulum. — Fractures of the rim 
of the acetabulum most frequently accompany dislocation of the 
femoral head. They may occur without dislocation, sometimes with 
splits in the head or a chipping out of small fragments. Extent of 
the rim fractures varies. The upper and posterior portion is the usual 
site of fracture, and the area broken off may be in one piece or several. 
Avulsion of the capsular ligament may tear off a small shell of bone. 

When not connected with dislocation, the condition may be undiag- 
nosed even if a roentgenogram is made. In obscure cases, as stated 
under Fractures of the Head of the Femur, dried Roentgen pictures of 
both hip-joints, taken in the same position, must be studied. Dis- 
locations and fracture of the femoral head may be differentiated by 
the relative position of the leg and thigh, a flexion and inward rotation 

1 Ann. of Surg., vii, 754. 2 Southern Med. Jour., July, 1914. 

3 Northwest Med., June, 1914. 

* Univ. Penn. Clinic for Am. Orthop. Assn., June, 1813; Tr. Am. Jour. Orthop. Surg., 
xii, No. 2. 



FRACTURES OF THE ACETABULUM 581 

in dislocation, and an eversion and extension in fracture. After reduc- 
tion of dislocation a crepitus may be felt from a loose fragment of the 
rim, or the femur may easily slip out of place. Crile reported a case 
in which nearly one-half the acetabular rim was broken off at the base.^ 

Pain and soreness in the hip-joint are the constant symptoms. 
Because of these, use of the joint is restricted, and partial ankylosis 
is likely to follow. This arises from one of two conditions or from 
their combination. Pain and lack of use in the joint cause a shrinking 
of the capsule and a stift'ness of the periarticular tissues and muscles. 
Between the fragment and the pelvis callus or exostoses may form, 
which inhibit free motion and use of the joint. 

Treatment. — The treatment consists in the immobilizing of the hip 
in a plaster spica in abduction, for three or four weeks, and then the 
starting of progressive use which is persisted in if not painful. If use 
distresses the patient, it is better to reimmobilize for another month. 
When ankylosis develops in the joint, breaking up of adhesions under 
anesthesia is of no assistance; the curative treatment rests in an 
open operation and an arthroplasty after removal of the excess callus 
and misplaced bone. Recent cases after dislocation which will not 
remain reduced may be subjected to open operation and the loose 
fragments nailed into place or removed. 

Radiating Acetabular Fractures. — Radiating acetabular fractures, 
including fractures of the floor and epiphyseal separation, arise from 
violence received on the trochanter or on the leg and transmitted to 
the pelvis. The cracks may run into all three of the pubic bones, 
or be confined quite closely to the acetabulum itself. The pubic por- 
tion is more likely to be broken clear through and suffer displacement, 
while the iliac and ischial portions are simply split slightly. The 
patient may be able to walk after the accident, always with pain, 
weight being supported on the intact portion of the acetabulum. If 
there has been a sinking in of the whole acetabular area, the trochan- 
teric region will be flattened, abduction limited, and the whole leg a 
little shortened. 

Xeuhof- believes that there are few museum specimens that show 
any possibility of complete or partial separation of the epiphysis of 
the three bones uniting in the acetabulum."^ He reports the first case 
of acetabular separation of juvenile pelvic bones, unassociated with 
other pelvic lesions. The child was a six-and-a-half-year-old girl, who 
fell on her hip. There was painful walking, a slightly less prominent 
trochanter, and a fuller Scarpa's triangle on the injured side. Rectal 
examination usually shows tenderness on the affected side; pressure 
on the trochanter toward the joint or compression of the pelvis is 
painful. 

Treatment. — The treatment consists in a plaster spica applied with 
the leg in abduction, as given previously.'* 

' Ann. of Surg., xiii, .37.3. 2 Ibid., Ix, .307. 

^ Poland, "Traumatic Separation of the Epiphyses," 1898. 

* Kontorowitch, T'ontrib. a Tetude de Frart. du Bassin. Frart. simp, et limitoc 
de la cavite cotyloide. Th^se de Lyon, 1903; Grube, Rev. de Chir., 1904, xxix, 60; 
Thevenot, Rev. de Chir., Februarj', 1904; Thevenot, Rev. de Orthop., March, 1904. 



582 



FRACTURES AND DISLOCATIONS OF THE PELVIS 



Intrapelvic displacement of the femoral head or central disloca- 
tion of the femnr results from the same causes with a greater degree 
of, and more prolonged, violence. The displacements may be of two 
kinds. The head of the femur is pushed in through the cotyloid cavity, 
carrying the bottom of the acetabular bone before it, or, more com- 
monly, the floor of the acetabulum is split through and the femoral 
head and neck driven into the pelvis. Abduction probably favors 
this dislocation fracture, because in falls on the feet, the thicker upper 
portion of the acetabulum resists the force, but if abduction is present, 
the thinner pubic portion bears the brunt of the punch. Muscular 
force and contraction may prevent reduction (see Fig. 390). This 
dislocation requires great violence, and a severe injury is apparent. 
Usually the trochanter has become sunken. Hip movements are 
possible but painful and restricted, depending on the size of the hole 




Fig. 390. — Penetrating fracture of the acetabulum by the femoral head. Central or 
intrapelvic dislocation of the head of the femur with fracture of the pubic ramus. 



punched in the pelvis. Crepitus is usually present in the hip. The 
leg is in eversion and there is shortening, varying from one to two 
inches. Rectal and vaginal examination permit palpation of the 
displaced head of the femur. Abdominal tenderness is also present. 
The associated injuries may be very severe and quickly fatal. Injury 
of the rectum and bladder and urethra, or rupture of the iliac vessels 
are reported. On the other hand, the symptoms may all be lacking 
except the finding of displacement, and the patient may be able to 
walk and work at once. Adams^ reported one case of this kind, the 
roentgenogram confirming the displacement and making the diagnosis 
positive. Four cases with pictures have been recently reported by 
Ewald.2 

1 Boston Med. and Surg. Jour., 1907, 432. 

2 Ztschr. f. orthop. Chir., xxxiii, Heft 3-4. 



FRACTURES OF THE ACETABULUM 



583 



Course: Use, especially when not painful, can cause a new socket 
to develop aroiuid the displaced head and function becomes satis- 
factory in spite of the leg shortening. Ankylosis also develops. The 
mortality is 50 per cent., 22 out of 44 cases mentioned by Fuller,^ and 
is largely due to the associated injuries. In uncomplicated cases the 
prognosis is quite favorable. Schiller's case went undiagnosed for 
11 months, and was ankylosed in flexion, abduction, and outward 
rotation.- 

Difterential diagnosis must be made between this condition and 
fracture of the femoral neck with impaction or erosion, and the dis- 
locations of the hip. Hamilton says this can be done by the finding 
of crepitus as soon as the leg is moved, while in neck fractures with 
separation, crepitus does not occur until the fragments are brought 
into apposition. In the anterior dislocation of the head of the femur 
it can be seen and felt, in the dorsal dis- 
location, the trochanter lies above Nelaton's 
line and the thigh is flexed and adducted, 
and in thyroid dislocations the leg is 
lengthened. 

Treatment. — In uncomplicated cases reduc- 
tion can often be made under anesthesia by 
lateral traction, the possibility of reduction 
depending on the size of the hole punched 
out. The pelvis is firmly fixed by means of 
bandaging and pressure by assistants, and 
the lateral pull on the thigh is made by the 
operator until the femoral neck is felt slip 
out (Fig. 391). If the hole is large and the 
muscles are powerful, strong tendency to 
recurrence may exist. In such a case the 
possibility of resecting the head of the femur 
by open operation will present itself. This 
is done to avoid ankylosis or pressure. 

Loepp^ reports a case of central dislocation in a forty-year-old man 
who fell five feet and landed on his right hip. The right leg was rotated 
outward, flexed and abducted and was 3| cm. shorter than the left. 
There was a puckering of the skin over the greater trochanter which 
was drawn nearer the middle line. Reduction was made by means of 
extension and lateral pull on the thigh but no crepitus was noted, 
probably because of the size of the hole in the pelvis. The femur 
tended to slip back again into displacement when traction ceased, so 
the leg was placed in extension with a weight of twenty pounds hung 
on. Catheterization was necessary, but there was no blood in the 




Fig. 391.— Method of re- 
ducing central dislocation of 
the hip. (After Cotton.) 



1 Am. Jour. Med. Sci., 1911. cxli, 385. 

* Moore, Med. Chir. Tr., xxxiv. 107; Arreger, Deutsch. Ztschr. f. Chir., Ixxi; Schloffer, 
Arch. f. klin. Chir., Ixxxiv, 499; "Womers, Beitr. z. klin .Chir., lii, 185; Schroeder, North- 
west Univ. Med. School Quart. Bull., 1912. 

» Arch. f. klin. Chir., Bd. cii, 1092. 



5S4 FRACTURES AND DISLOCATIONS OF THE PELVIS 

urine. The final result showed IJ cm. shorteniug, the head of the 
femur was in the acetabulum and all movements of the hip except 
adduction were good. Extension should remain on the leg about 
three months, and the subsequent use of the leg should be light for 
three more months. 

The complications of bladder and bowel rupture or hemorrhage are 
treated by immediate open operation. 



FRACTURES AND DISLOCATIONS OF THE SACRUM. 

Longitudinal cracks and fissures have been discussed. They are 
rare. Dislocations of the sacrum from opening of the sacro-iliac joints 
are rare and caused by great violence. Most cases are fatal. Other 
injuries often accompanying them. Diagnosis is made on external 
and internal vaginal and rectal examination. If reduction can be 
made by digital pressure within the rectum or vagina, that should 
be done, and the patient should be put on a water bed or Bradford 
frame with soft pads to avoid pressure necrosis in the sacral area. 
If complete dislocation is present, paralysis of bladder, rectum, and 
the legs would be present from injury of the sacral plexus. Stimson 
reported a case. 

Transverse fractures of the sacrum are caused by falls on that 
area or a blow or kick from behind. The usual displacement is that 
of the lower fragment forward into the pelvis, with a line of separation 
just below the sacro-iliac joint. Oblique fractures are very rare, and 
Roentgen-ray study is revealing an increasing number of incomplete 
cracks and fissures. 

Sloughing of the sacral tissues, interference with bladder and 
rectal action on account of injury of the sacral plexus and other 
intrapelvic pathology, which goes with pelvic fracture, may be com- 
plications. 

Symptoms. — The symptoms are great pain in the sacral region, 
displacement of the bone fragment, and visceral disturbances. Exami- 
nation externally and via rectum or vagina demonstrates the mis- 
placed bone or the extreme tenderness of linear cracks. Coughing, 
defecation or even breathing are painful, and the fragment can be 
moved by the finger in the rectum. Nerve injury corresponds to that 
found in dislocations. 

Treatment. — Treatment is similar to that of dislocation of the sacrum. 
Attempts to pad the fragments into position by a rectal or vaginal 
packing are not successful and always cause intense pain and run the 
risk of causing necrosis of the walls. It is impracticable to pack the 
rectum and allow drainage through a tube for the escape of excreta. 
Open operation for the fixing of the sacrum in position when reposi- 
tion fails to hold the displaced fragments has not been reported, but 
it is feasible. 



FRACTURES AXD DISLOCATIONS OF THE COCCYX 585 

FRACTURES AND DISLOCATIONS OF THE COCCYX. 

These are rare, and reports of verified cases are not frequent. 
Women are more frequently concerned than men. INIost cases arise 
from falls on a sharp edge, as on a child's block or across a fence. 
They may also follow trauma of horseback riding or, as in one case 
I have seen, be caused by the jar sustained by the patient riding on 
the '' scenic railway" in an amusement park. Dislocations of the coccyx 
are also frequent in obstetrical practice. When the pelvic joints 
become softened prior to the time of labor, dislocations of the coccygeal 
portion may arise from slight trauma or muscular action. I have seen 
one case in which there was no history of trauma and which could 
be accounted for in no other way than by muscular action. During 
the passage of the child's head these dislocations are also seen. 
Whether there is a true fracture at the sacrococcygeal junction or a 
stretching of the ligaments which permits the displacement has not 
been decided. The symptoms are pain in the coccygeal region, 
increased by pressure or even by sitting or lying on the back. Defeca- 
tion is also painful, as the bone is usually displaced forward. In 
traumatic cases there may be ecchymoses or swelling found externally 
in the coccygeal area. Complete dislocation may be forward, back- 
ward, or lateral. The former is the most frequent; backward or 
lateral displacements are rare and are due to some special trauma. 
Pain is severe immediately after the trauma and radiates down the 
inner side of the thighs. In obstetrical cases, those w^hich occur before 
labor in the later months of pregnancy may cause great uneasiness 
and by constant irritation make life miserable for the patient. Dis- 
locations occurring during labor may go unnoticed for several days or 
weeks, until the patient gets up and walks. 

Diagnosis. — Diagnosis is made on the external evidence of swelling 
and ecchymoses with pain on pressure in acute traumatic cases. 
Lateral fracture dislocation can be detected by the finding of the 
loose and painful fragment on one side of the gluteal fold in a swollen 
area. Posterior and anterior displacements are recognized by external 
examination aided by a finger in the rectum or vagina. The displaced 
fragment is usually freely movable and examination extremely painful 
in recent cases. Disturbances of sensation are found when the sacral 
plexus is involved. Bladder and rectal action may also be interfered 
with. The patient may be unable to lie on the back, or even sit on 
padded cushions, or pneumatic rings, preferring to lie on the side. 
Osteo-arthritis may develop and lead to a condition of chronic or con- 
stant pain which shatters the patient's general health and leads to 
narcotic habits, great constipation, and mental disturbance. " Coccyg- 
odynia" is the term appHed to these painful conditions which follow 
any of the previously mentioned causes. 

Treatment. — In recent traumatic cases the fragment may be 
replaced by a finger in the rectum or vagina and pain greatly alleviated. 
Hot applications, anodynes and rest are indicated until acute effects 



586 



FRACTURES AND DISLOCATIONS OF THE PELVIS 



subside. If the pain and distress continue and eoccygodynia is diag- 
nosed, the only permanent reUef which can be promised is from opera- 
tive removal of the coccyx. As a rule the cases in obstetrical conditions 
become well after replacement and rest.^ 

Operation is performed through a midline posterior incision, the 
bone being separated and the fragment removed by dissection through 
the sacrococcygeal junction. Relief is due to the severance of the 
coccygeal nerves or their release from pressure by the misplaced bone. 
The operation requires rigid asepsis and a semiprone position during 
healing of the wound. 




Fig. 392. — Incomplete fracture of the wing of the ilium. 

FRACTURES OF THE ILIUM. 

Fractures of the ilium involving the crest and spines, and not involv- 
ing the pelvic ring; are due to direct violence and muscular action. 
Hamilton recorded a case of fracture of the posterior superior spine 
caused by a fall on the back. Direct violence of falls, where the iliac 
crest strikes the ground or knocks against a heavy object, causes a 
separation of a whole or a part of the edge of the crest. A small area, 
usually triangular in shape, may be loosened and driven in toward 



Haurant and Pigache, Rev, de Chir., January, 1914, xxxiv, No. 1. 



FRACTURES OF THE ILIUM 



587 



the abdominal cavity. In childreli the upper epiphyses for the crest 
may separate, but this is not an extensive displacement on account 
of the wide attachment of the abdominal muscles, the internal and 
external oblique and transversal is, which tend to hold the broken 
fragment in position. If these muscles are torn loose at the time 
of accident, the displacement is greater and the fragment is usually 
pulled upward (see Fig. 392). 

The anterosuperior and inferior spines are broken off by direct 
violence of a sharp blow. The displacement is not great, and the 
condition may not be recognized. Fracture of the anterosuperior 




Fig. 393. — Fracture of the anterosuperior iliac spine by muscular action. 



spine caused by muscular action is very interesting. The literature 
contains but six or eight cases, but I believe the condition is fairly 
common (see Fig. 393). They may be caused by heavy weights falling 
on the tense abdomen and striking the anterior iliac spines or exerting 
a tearing-out stress on the muscles attached on the bony point, or 
sprain fractures from muscular action of the thigh group. Cases have 
been reported by Ruppert^ and Skillern^ and others. Sprain fractures 
are rare and happen when the patient is running. There is sharp pain 
in the anterosuperior iliac spine and patient generally has to stop. 

' Wien. klin. Wchnschr., 1914, xxvii, 700. 
2 Ann. of Surg., Ivii, 289. 



588 FRACTURES AND DISLOCATIONS OF THE PELVIS 

In Skillern's case the patient was able to run five yards, the accident 
happening as a race was finished. Attached to the spine are the gluteus 
medius, the tensor fascia lata, and the sartorius. The first two muscles 
are internal rotators of the leg, and the sartorius is a pronator of the 
knee. The mechanism is probably as follows: in running, the leg 
involved is stretched way out behind as a step is being taken with the 
opposite leg. The ground may give way or the foot slips, so that 
simultaneously with the hyperextension an outward rotation of the 
leg takes place. This passes the limit of extension permitted in the 
hip-joint, and the spine is pulled off by the muscles named. 

Diagnosis. — Diagnosis is made by the pain on the crest or spine, by 
deformity of local displacement, and by crepitus of loose fragments. 
Loss of function varies. If the spines are involved, there may be 
inability to walk. When the crests are ruptured, abdominal pain and 
tenderness often predominate. Hyperextension of the thigh will cause 
pain in the spines or crest. 

Course and Prognosis. — Crushing weights on the abdomen may cause 
death from complications. Fractures and displacements of the crest 
or epiphysis usually unite by bony union in four to six weeks. Per- 
manent deformity, arising from a flaring out or drooping of the crest 
involved, may be found after union. Rarely fractures of the anterior 
superior spine, which are not given rest, fail to unite and there is 
found a loose, painless fragment after many weeks. I have seen one 
case of this character after an injury in a football game. The usual 
result is bony union. 

Treatment. — Treatment consists in strapping of the pelvis or in 
application of a plaster-of -Paris cast to immobilize the pelvis and both 
thighs to the knees. This should be left on at least four weeks. Frac- 
tures of the anterior spines demand immobilization of the leg on the 
affected side in extension, or in very slight displacements, the fragment 
can be held in position by strapping. If a large corner is broken off, 
it can be nailed on with a cigar-box nail. 



CHAPTER XXII. 
FRACTURES OF THE FEMUR. 

From January, 1907, to May, 1914, at the Cook County Hospital, 
Chicago, out of a total of 10,702 fractures, 999, or 9.3 per cent., were 
of the femur. Stimson shows in his statistics from the Hudson Street 
Hospital in Xew York City, 540 fractures of the femur, a percentage 
of 3.7. Statistics of former collections by other authors also give a 
lower percentage than that obtained at the County Hospital, a cir- 
cumstance which may be attributed to the two following facts: that 
the more recent figures cover the use of the Roentgen rays in traumata 
and that on account of crowding in the hospital, cases of fracture of 
minor importance are dressed and turned away without record, and 
of those kept in as patients the proportion of injured femora is large. 
It may also be said that relatively few cases of dislocation of the femur 
are received, because of improved diagnosis by the Roentgen rays, 
and that older records which gave a relatively higher percentage of 
dislocation, could they have been searched by the Roentgen rays as 
now, would reveal far fewer dislocations and more instances of fracture. 

Anatomy. — The femur, the longest bone in the body and most 
important as the link between the trunk and leg is also a lever much 
like the humerus. Its movements at the hip are somewhat more 
restricted than those of the humerus at the shoulder, but its ball- 
and-socket joint permits a wide range. At the upper end the neck is 
attached at about an angle of 130 degrees. The angle of inclination 
( cervical angle or femoral angle) is formed by two lines, one through 
the longitudinal axis of the shaft, the other through the long axis of 
the neck, and is normally 125 to 130 degrees. Hoffa's line through 
the base of the neck, perpendicular to the long axis, extended, meets 
the extended long axis of the femur in an angle called Alsberg's angle, 
or angle of direction, which varies in normal limits from 41 to 44 
degrees.^ 

Hip Joint. — The head, held to the acetabulum by the ligamentum 
teres, i> covered by the strong divisions of the capsular ligament, 
those fibers arising from the ischium behind, from the ilium above, 
and the pubic ramus in front, uniting in a long, strong insertion in the 
linea trochanterica in front. No attachment is afforded these at the 
base of the femoral neck posteriorly. The joint synovial capsule is 
inserted near the base of the neck and is reflected on the neck, head of 
the bone and ligamentum teres, to its insertion in the acetabulum and 
ligamentum transversum acetabuli, leaving a part of the neck, which, 

' Tubby. British Med. Jour., July 25, 1908. 



590 



FRACTURES OF THE FEMUR 



while intracapsular, is outside of the joint. In front the capsular 
ligament covers the whole neck, the attachment being about three- 
fourths inch in front of the intertrochanteric line. 

Knee-joint. — The stability of the knee-joint depends largely on the 
crucial ligaments, the extrinsic ligaments and muscles, as the bone 
surfaces are not closely adapted to each other and much motion is 
necessary. On the outer side is the external lateral ligament, strength- 
ened by the biceps femoris tendon, extending from the external 
tuberosity of the femur to the head of the fibula to be attached 
between the two heads of this tendon. Many knees, according to 



Appears at 
4:th year ; 
joins body 
about ISth yr. "^ 



Appears at 

9th month of 

foetal life 




Appears at 
end of \st yr. ; 

joins body 
about ISth yr. 



Appears I3th-14ih 
year ; joins body 
about \^th year 



Joins body at 
20th year 



Lower extremity 
Fig. 394. — Plan of ossification of the femur. From five centres. (Gray.) 



Jones,^ show also a shorter posterior band of this ligament. The 
capsule of the joint proper is a separate structure, and the external 
ligament is also separated from the external semilunar cartilage by 
the tendon and bursa of the popliteus. 

The internal lateral ligament is a long, fan-shaped, fibrous struc- 
ture of great importance to the joint, its deep fibers intermingling 
with the true capsule and becoming attached to the internal semilunar 
cartilage. To make this insertion and blend with the transverse 
fibers of the cartilage, the deep fibers have to turn in toward the joint, 



Ann. of Surg., 1, No. 6, p. 



FRACTURES OF THE FEMUR 



591 



and as a consequence are much shorter than those found on the outer 
side of the knee. The lateral ligaments are assisted by the presence 
of the disks of the semilunar cartilages, which are crescentic in shape, 
thicker at the convex margin, thinning out on the concave side. By 
means of their wedge shape each cartilage supports the action of the 
opposite lateral ligament in resisting lateral movements of the leg, 
and also aids in making the crucial ligaments tense. 

At the neck, the angulation of attachment may vary, even in the 
same individual, as has been shown by many roentgenograms. This 
difference may lead to a slight real shortening of one leg, wiiich is not 




YiG. 395. — Longitudinal section of head and neck of femur. (Gray.) 



noticed when the leg is undiseased and no trauma has included the 
I)art, because the pelvis tips enough to equalize the difference and 
gives no apparent shortening. Traumata of the hips in infants and 
children mechanically cause angular variations, impactions, or axial 
changes, without causing enough disabihty to be regarded as more 
than a })ruise.' 

Structure. — Ossification takes place from five centres, for plan of which 
refer to Y'lg. 394. The structure of the body of the femur is that of a 

1 Savariand, Bull, et mem. Soc, de Chir. de Paris, 1914, N. S., xl, 406. 



592 



FRACTURES OF THE FEMUR 



cylinder of compact tissue, in which the large medullary canal lies. The 

wall is strongest and thickest and assumes almost a triangular shape 

near the middle of the shaft, where the medullary canal is small and very 

distinct. At the ends of the bone the compact layer becomes thinner 

and the medullary canal smaller until it is filled with cancellous tissue. 

The structure is of great importance in connection with fracture of 

the upper and lower ends of this 

bone. At the ends, the lamellae or 

truss rods of support inside are 

placed in the lines of greatest 

pressure. In the neck they are 

arranged as Gothic arches; chief 

lamellae at right angles to the 

articular surface run together to 

form a strong central bone wedge 

which lies in the neck and extends 

out to the epiphyseal line, being 

supported in the head itself by 

lamellae extending to the sides of 

the neck along both upper and 

lower borders. Force applied to 

the head is transmitted along this 

central bone wedge and on down 





Calcar 
femorale 



Fig. 396. — Scheme showing disposition 
of principal cancellous lamellae in upper 
extremity of femur. (Gray.) 



Fig. 397. — Oblique section of upper 
extremity of femur showing calcar femo- 
rale. (Gray.) 



to the body of the bone, spreading out over these strong truss-like 
bands. In addition there are two supporting bars, one from the 
lesser trochanter to the superior border of the neck, and the other 
across the union of the greater trochanter with the femoral neck (Figs. 
395 and 396). The neck also contains a vertical plate of bone, the 
calcar femorale (Fig. 397), as described by Bigelow, which reinforces 
it and passes down below the trochanters to take origin from the 



FBACTURES OF THE UPPER END OF THE FEMUR 



)9; 



centre of the medulla. At the lower end the strong lamelh^ pass down 
perpendicularly to the knee-joint and are crossed at nearly right angles 
by planes of cancellous tissue. 



FRACTURES OF THE UPPER END OF THE FEMUR. 

Fractures of the Head. — ^These fractures are rare and may be classed 
as follows: 

(1) Crushing, either in connection with fracture of the acetabulum 
and central dislocation, or by impact against the acetabular rim, or 
an exostosis as reported by Stimson.^ 





Fig. 398. — Linear fracture of the head 
and fracture of the neck. The position of 
cversion of the leg is apparent from the 
displacement of the neck. 



Fig. 399. — Fissure through the epiphysis 
of the femoral neck -u-ith little separation. 
The tip of the greater trochanter has been 
fractured through its epiphj-sis and the 
acetabular wall is punctured. Cause, direct 
violence on the hip. 



(2) Linear cracks, with or without separation, and frequently from the 
base of the ligamentum teres down the long axis of the neck (Fig. 398). 

(3; Tearing off of a small fragment by the pulling out of the liga- 
mentum teres, or direct violence against the acetabular edge. 

Careful roentgenograms, as the technic of exposure for the hip-joint 
has improved, have shown these smaller fractures. If the crushed 
portion is not displaced and does not interfere with joint motion, no 
treatment is indicated, but if the displaced fragments cause pain or 
hmit motion, removal may be indicated. If completely detached 
these fragments eventually become smoothed off like a sesamoid, or 
jrradually absorbed (see Fig. 399). 



' New York Med. Jour., August, 1889, p. 1G3. 



38 



594 



FRACTURES OF THE FEMUR 



Fractures of the Neck of the Femur — These may involve any part 
of the neck but usually are near the head, or near the trochanters at 
the base. They are classified as follows: 

(1) There may be fissures or incomplete cracks accompanied or 
not by bending of the neck, shortening of neck and leg, or other change 
in the neck. Hamilton {Fractures and Dislocations) thought these 
fractures were improbable, but Colles^ considered that three out of 
eight cases seen by him were complete. It is now established by the 
Roentgen-ray examinations that these are found, and the joint capsule 
or periosteum may be torn or not. The presence of fracture depends 
on the cause, the amount of force, and the individual's age, governed 
by the lines of deposition of the majority of the lamellse in the neck. 




Fig. 400. — Fracture high up through the 
femoral neck. Absorption of both fragments 
by attrition and displacement upward of the 
shaft. 



Fig. 401. — Fracture of the femoral 
neck with driving in of the lower 
fragment. Note the callus formation 
about the acetabular edge which 
probably denotes fracture there. This 
bony growth greatly restricted motion 
in the joint. 



(2) Fractures of the neck just below the head are common (Fig. 
400). Complete fracture with or without separation with slipping 
of the neck up on to the ilium, occurs. If the neck passes upward, 
shortening of the leg, outward or inward rotation may be found. 
If the fracture force divides into such directions that part of its plane 
extends in the direction of the longitudinal axis of the neck, as in falls 
on the buttock or trochanter, impaction follows the driving of the neck 
into the head fragment (Figs. 401 and 402). The question of the value 
of impaction can be settled on a rational basis if one bears the follow- 
ing facts in mind : When the fragments are impacted all teaching has 
been to leave them alone and not destroy the impaction for fear of 

1 Dublin Hosp. Rep., ii, 339. 



FRACTURES OF THE UPPER END OF THE FEMUR 595 

removing the blood siipph' from the head and thus causing its necrosis, 
or at least causing delayed or fibrous union. The author believes 
impaction has little bearing on the prognosis of these two points, and 
is of little importance except in old persons, when it has value in 
promoting or holding bony continuity. In the young and in adults, 
proper reduction is of more importance than impaction, and if this 
cannot be accomplished without destroying the latter, impaction 
should not be considered at all. To illustrate, if an impacted fracture 
of the neck occurs in a young adult with unfavorable position of the 
leg, or shortening, the impaction should be broken up and the leg 
brought into proper position to favor full ultimate return of function 
without shortening.^ 

The viability of the head does not rest on impaction of the neck 
into it, but depends on the integrity of the vessels which supply the 




Fig. 402. 



-Fracture of the neck and also through the trochanteric line, the latter being 
impacted. 



head. These arrive by way of the capsular insertion into the perios- 
teum of the head, so that viability of the head fragment is a question 
of their injury or thrombosis from extensive laceration of the capsule 
rather than fracture of the bone tissue. If the function of these vessels 
is destroyed, late necrosis of the head follows. 

Formerly it was supposed that fractures of the neck were found 
only in elderly people due to slight trips or falls on account of the 
rarefying of the bones incident to age and a change in the axis of the 
neck of the femur. Walker^ states that the condition is a senile osteo- 
porosis which is caused by disease of the vascular walls supplying the 
neck. Tliis causes bone weakness, the cortex becomes thinner, some 
of the lamelhe of the spongiosa are absorbed, and fracture more easily 
results, so that a slight trauma or twist in an adult is all that is needed. 

' Jones, Proc. Roy. Med. Soc, December, 1910. 
2 Ann. of Surg., xlvii, 84. 



.596 FRACTURES OF THE FEMUR 

Of his 112 cases, 51 over sixty years of age were caused by a slip or 
fall on the floor or sidewalk, and 28 cases to falls from a ladder or 
scaffold, or downstairs; 18 cases caused by falls from a height, loft, 
elevator, etc., were all under fifty years of age. 

(3) There may be fracture of the neck and separation of the upper 
epiphysis in children. 

Whitman^ reported 18 cases of fracture of the neck in children all 
under eight years of age seen by him in ten years. These cases differ 
from those of elderly people in that helplessness and persistent dis- 
ability are not present. The conclusion is reached after a few days, 
because the child can walk, even though a limp and some pain are 
present, that the trauma caused merely a contusion. Careful examina- 
tion w^ould show, however, actual shortening of one-half to three- 
fourths inch, with a corresponding elevation of the trochanter, which 
is usually found displaced forward toward the anterior superior iliac 
spine. Slight outward rotation is common. Some lameness and dis- 
comfort may last for months because of slow interrupted bone repair, 
and extreme motions of the hip- joint are painful. This contrasts 
with the condition of fracture of the neck in old people in whom the 
disability is immediate and prolonged. In childhood the disability 
is short, the return to functional use very quick, if not immediate, 
but the femoral neck has been weakened and placed in a new position 
subject to greater strain in weight-bearing which leads to actual 
shortening, limp and disability later. Albee^ quotes Rotch as saying 
that the Amazons used to separate the upper femoral epiphyses of 
their male infants to promote their own supremacy, so lasting was 
the resulting disability. Diagnosis is not made early unless recourse 
to roentgen ray is had. The symptoms continuing are likely to 
progress into a coxa vara, or simple depression of the neck, predis- 
posing to continued deformity. Late diagnosis with a differentiation 
from tuberculous coxitis is forced. Walker finds that there were 

9 cases in his series under thirty years of age. Whitman later details 

10 cases of this fracture in children seen three weeks to six months 
after the accident, all of which had been diagnosed as hip disease. 
He reiterates the following points of diagnosis differentiating from 
tuberculosis : 

(1) The child has been previously in sound health. 

(2) In cases of fracture the trochanter is elevated; there is a change 
of hip contour on account of the approximation of the trochanter to 
the anterosuperior spine, and the leg is shortened and everted. 

(3) Late cases give a history of limp subsequent to some trauma, 
pain referred to hip and knee, restricted motion at hip. 

Walton^ takes another view of this question and says that the 
epiphysis of the head of the bone, which joins the shaft from the 
eighteenth to the twentieth year, is probably more often separated 
in part or completely than any other epiphysis of the body. The 

1 Ann. of Surg., 1900, xxxi, 145. 2 Am. Jour. Orthop. Surg., viii, 602. 

' Fractures and Separated Epiphyses, 1910. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 597 

c[iiestion of the site of injury, lio\ve\'er, is debatable because of the 
fact that sudden ^•iolence apphed to the femur is more apt to cause 
bending of the neck than a separation at the better protected and 
stronger epiphysis within the capsuhir structures. If fracture occurred 
at the epiphyseal line involving in part the articular surfaces, and 
separation of fragments was such that three-fourths inch shortening 
resulted, the joint function would be greatly impaired at once by the 
bony irregularity or later by callus thrown out. Great force is needed 
such as could be applied to the epiphysis only by means of projecting 
processes to which muscles and ligaments are attached, but this 
epiphysis is less liable to this leverage than any in the body. 

The truth probably lies midway between these views, and there 
seems to be no reason why the epiphysis of the thin neck of the femur, 
exposed to the severe strains of the body weight, should not give in 
an analogous manner to the epiphysis in other parts of the body, 
notably in the radius, as I have demonstrated.^ Similar cases are 
recorded by Albee- who cared for one, a girl aged thirteen years, and a 
year later had her referred back to him by a colleague as a case of 
tuberculosis. A second case in an eighteen-year-old male, the separa- 
tion having occurred four years before, had the limp as the only 
sjTnptom, and the roentgenogram showed the flattened head with 
the epiphysis displaced and firmly united with the projecting corners 
worn off. Bruns, in 100 epiphyseal separations, found but 1 of this 
kind.^ As mentioned, however, the disability is not immediate in 
children, many walking away from the scene of their fall or accident. 
Hence, as is found by the Roentgen-ray examination, the neck suffers 
later. At the meeting of the American Orthopedic Association Bolton 
demonstrated this theory by the presentation of an anatomical speci- 
men removed from a boy of eight years who fell six stories and failed 
to obtain any union in four weeks; at the same time Meyers and Stan 
showed similar specimens removed at autopsy. SprengeP disagrees 
with Whitman and reports two cases of epiphyseal separation in 
adolescents aged seventeen and eighteen years. This is refuted by the 
argument that it is not true that the epiphyseal line is a weak one and 
that separation through it is more common than fracture; because 
if this point is weak it is more so in adolescence than in childhood 
before the external cartilage and resistant periosteal cover have 
diminished to nearly an adult condition. Contributary causes are 
rickets, septicemia, syphilis, starvation, scurvy and prolonged mercurial 
treatment. In adolescents we should expect epiphyseal separation 
to be caused by slight violence. Schwarz,-^ writing on the question 
of spontaneous epiphyseal separation in children (intracapsular), 
records 3 cases of such separation following several months to a year 
after fracture of the neck of the femur, in which bony union and good 
function had been established. The epiphyseal separations occurred 

' Surg., Gynec. and Obst., August, 1913, p. 241. - Loc. cit. 

' Arch. f. klin. Chir., xxvii, 24. " Ibid., 1898, Band xlvii, S. 805. 

■' Beitr. z. klin. Chir., Tubingen, 1913, Ixxxvii, 709. 



598 FRACTURES OF THE FEMUR 

without known severe trauma and were ascribed to a rarefying process 
taking place after the child began to use the limb. These cases were 
all under observation and were checked by examination and roent- 
genograms. Schwarz's article contains an excellent bibliography on the 
subject up to that time. The epiphyseal cartilage and area in young 
children are proportionately thicker and larger than the shaft of the 
femur, as all the head and neck structures are first one cartilaginous 
mass, so that this mass, to quote Albee, acts as a "shock absorber'' 
and is less liable to disruption. Traumata followed by dislocation 
in the adult lead often to epiphyseal separation in the adolescent. 

Fracture of the femoral neck in childhood is practically then trau- 
matic coxa vara. The first symptoms are after slight trauma compared 
to a more severe injury in fracture of adults, with resulting deformity 
at the epiphyseal line. If the shortening is very little and the trochan- 
ter not prominent, there may be impaction. In other cases the femoral 
neck is depressed downward and backward. Disability is slight or 
absent, and it is concluded that the cortical substance over the epiphy- 
seal junction may have been broken and the newly formed bone 
beneath has gradually yielded after use. Immediate diagnosis should 
be made, and the neck replaced in normal position by traction and 
fixation in extreme abduction and inward rotation in plaster of Paris, 
with inhibition or weight-bearing until the bone is firm. Supervision 
looking toward avoidance of long periods of standing or violent exer- 
cise must be made, and prognosis as to final position in cases seen 
late, with deformity already present, or if the deformity progresses, 
should be guarded. It is desirable to change the cervical axis, but 
further depression of the neck can be avoided by the use of an ambula- 
tory splint or a perineal crotch worn for six months to take weight 
off the neck. When the depression has changed the angle from its 
normal 130 degrees to nearly a right angle the tendency to further 
descent until the trochanter rests on the ilium is very great. Cunei- 
form osteotomy offers the only hope of permanent cure of the 
deformity. 

Tubby calls attention^ to an opposite condition, coxa valga, the 
traumatic form of which follows fracture of the neck of the femur, 
impaction, malunion, or separation of the epiphysis. In coxa valga 
the limb is abducted with external rotation and limitation of adduc- 
tion, the hip- joint is painful, the gait rolling and unsteady with a 
limp, the trunk being inclined toward the affected side. The striking 
symptom is a lengthening of the limb of 2 to 3 cm. Treatment consists 
in fixing the limb in plaster in adduction or performing cuneiform 
osteotomy to straighten it. 

In adults fracture at the base of the neck is more frequent than near 
the head, and both involve the joint structures as mentioned above 
(Figs. 403 and 404). The former distinction of intra- and extracap- 
sular fracture is being dropped. It has little significance other than 

1 British Med. Jour., July 25, 1908. 



FRACTVRES OF THE UPPER EXD OF THE FEMVR 



599 



the placement, by the trauma of accident or subsequent manipuhition, 
of fragments of joint structures between the broken bone resulting 
in delayed or non-union. The displacement may be very little. The 
neck can slip well up posteriorly drawn by the glutei, rectus femoris 
and hamstring muscles beyond the head fragment, which remains 
in the acetabulum, or may be impacted to any degree. Cracks or 
separation with diverging lines of fracture into the trochanter at times 
accompany this form. 

Mechanism. — These fractures are caused by direct violence, acting 
on the greater trochanter in most cases as a smashing blow on the 
hip or a fall. 

Pathology. — The posterior part of the neck and greater trochanter 
are weaker and less protected by ligamentous structures and conse- 
quently suffer the most crushing and mashing. The head fragment is 




Fig. 403. — Fracture of the neck near 
the head. The neck fragment is in its 
customary position turned forward to 
permit eversion of the leg. 



Fig. 404. — Fracture of the neck near the 
base. The femur is also rotated outward a 
little. 



driven into this crushed mass of bone, the neck is shortened, and the 
angle of its axis is changed relative to its position on the femoral shaft 
in either plane, the apex of the angle being directed upward and 
forward. The line of fracture may be in any of the usual directions, 
most frequently transverse with serrations, or be limited to part of 
the neck only, the unbroken part preserving its continuity and peri- 
osteum intact, but undoubtedly bending (Figs. 405, 406, and 407). 
In cases of wide separation of fragments with shortening of the limb, 
complete bony rupture is found, perhaps subsequent to an impaction 
in the first part of the trauma. The periosteum may be completely 
severed with resulting necrosis of the head, as explained, or it may 
remain attached in one of several shreds, their width varying up to 
one-third the total of the periosteal covering. 

At first, shortening may be little, but in a few days on account of 



600 



FRACTURES OF THE FEMUR 



the tonic spasm of the muscles trying to hold the hip immobile, to 
avoid pain, the lower fragment is pulled up. Attempts at reduction 





Fig. 405. — Complete transverse 
fracture at the base of the femoral 
neck. There is a little shortening in 
this case. 



Fig. 406. — Fracture at the base of the 
neck with upward displacement of the shaft 
and consequent shortening. Slight impac- 
tion. 



which loosen the fragments, or complete loss of capsular tone because 
of laceration and hemorrhage, will aid this shortening. If weight- 
bearing is allowed in fractures at the base of the neck before the 
callus can withstand the strain a slow process of shortening follows 





Fig. 407. — Fracture of the base of the 
neck with shortening, impaction and ac- 
companying fracture of the pelvis. Cause, 
direct violence on the hip. 



Fig. 408. — Slow bending of the neck 
after a healed fracture. The angle is 
approaching 90 degrees and there is a 
condition of coxa valga. 



the bending of the neck (Fig. 408). If the trochanteric fragments 
have been separated and are numerous, the large callus can interfere 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



GOl 



with joint action, restricting it. Breaks in the neck near the head are 
likely to allow less callus formation on account of their protected 
l)osition and freedom of complication of trochanter damage. 

Fractures at the base of the neck into the trochanter are frequent 
and are the class former)}^ described as extracapsular fracture. The 
displacements are about the same as in fractures higher up on the 
neck, and in some cases, on account of the direction of the force applied 
on the trochanter, the shaft fragment is rotated inward and displaced 
backward so that the leg Hes in inversion (Figs. 409 and 410). The 
greater trochanter may be severely comminuted, large fragments 




Fig. 409. — Fracture through the 
trochanteric line (Kocher), the leg 
eWdently lies in eversion and the 
lesser trochanter is split, a common 
accompaniment. The rim of the 
acetabulum has also been splintered, 
probably by impaction of the head 
fragment. 



Fig. 410. — Incomplete fracture of the neck 
and slightly impacted fracture through the tro- 
chanteric line. The great trochanter is com- 
minuted. 



can be loosened and displaced by both violence and muscular action, 
or the trochanteric area can be impacted, and telescoped into itself 
with little axial displacement, but with shortening and other gross 
evidence of fracture. Every degree of injury from radiating cracks, 
violent tearing out of the whole trochanter and wide displacement of 
fragments is found, depending on the quantity, direction of the force, 
and the position in which the limb was at the time of trauma. Some 
portion of these injuries will surely involve the joint structure so that 
the sharp distinction of extra- and intracapsular fracture cannot be 
made and lacks clinical demarcation of value. 



602 



FRACTURES OF THE FEMUR 



Ashluirst^ believes that fracture of the neck at the junction with 
the greater trochanter is an uncomphcated fracture through the tro- 
chanter. As fractures through the trochanter are usually comminuted, 
violence applied to the trochanter major produces an impacted frac- 
ture through the neck and trochanter which was formerly called extra- 
capsular of the neck. The cancellous tissue of the greater trochanter 
is split by the firm wedge of bone in the neck, its wedging being 
responsible for two or three secondary fractures complicating the 
primary break (Figs. 411, 412, and 413). 

Cope^ describes three distinct injuries in this region: (1) Primary 
fracture at the junction of the head and neck, the base of the neck 
being then thrust through into the cancellous tissue of the greater 




Fig. 411. — Intertrochanteric fracture with displacement upward of^'the shaft. The 
neck fragment is correspondingly tilted up and the leg shortened. 

trochanter, with secondary but incomplete fracture through the tro- 
chanter; (2) separation of the trochanter due to pressure from the 
firm tissue of the neck. The tip of the greater trochanter is nearly 
always drawn inward toward the upper acetabular rim ; (3) a further 
stage when the lesser trochanter and a slice of the shaft also split off. 
Ashhurst adopts this classification, adding a fourth condition, frac- 
tures below the trochanter, either transverse or oblique, which merge 
into (3). 

Repair. — ^What percentage of fractures of the femoral neck result 
in bony union? It is impossible to say unless known cases were 
followed to their death and postmortem examination made of the 



' Ann. of Surgery, Iviii, 494. 

2 Treatise on Fractures and Dislocation of Joints, 1822, pp. 116-151. 



FRACTURES OF THE UPPER END OF THE FEMUR 603 




Fig. 412. — Comminuted and impacted trochanteric fracture. A large fragment has 
been torn ofif the anterior surface and the neck is impacted into the shaft. 




Fk;. 41: 



-Trochanteric fracture with separation and complete splitting off of the 
lesser trochanter. 



604 



FRACTURES OF THE FEMUR 



bone, but there are many specimens on record and in museums which 
show firm bony union which had histed for years. Ruth/ describing 
the Philiii)s-Maxwell method of treatment, showed several specimens 
obtained after death. Bony union is chiimed by him for all cases, and 
his specimens, some obtained not more than four weeks after the 
trauma, showed every evidence of bony consolidation. This method 
is dealt with fully under the head of treatment of this fracture (Figs. 
414 and 415). 

On the other hand, there are many cases of non-union, fibrous 
union, false joints, death of the head of the bone, and even suppurative 
and hyperplastic forms of arthritis which preclude bony union. In 




Fig. 414. — Fibrous union following fracture of the neck. Although there has been 
absorption of the bone of both fragments, the neck being absorbed down to the acetabular 
edge, there is not much shortening because the patient had not yet walked. 



adults up to middle age I believe bony union, or at least such union 
as is serviceable and cannot be distinguished from bony union, is the 
rule. In children practically all cases result in bony union with little 
interference with growth and an obliteration of deformity as age 
increases. Union of a fibrous character which is strong enough to 
allow weight-bearing function in the leg is satisfactory in many cases. 
(¥ig. 416). Particularly is this true in elderly people from the prac- 
tical standpoint. We must consider this fracture as a solution of 
bony continuity, and if solid union can be obtained, every effort should 
be made to get it even at some discomfort to the patient. In the old 

1 Albany Med. Ann., .January, 1913. 



FRACTURES OF THE UPPER END OF THE FEMUR 605 




Fig. 415. — An unusual form of the trochanteric fracture which healed by bony union. 
The patient was allowed to walk too soon with secondary displacement and shortening 
Note the neck anjile. 




liG. 41G. — Fracture of one femur at base of the neck and traumatic coxa vara on the 

other side in a child. 



GOG FRACTURES OF THE FEMUR 

we are rather inclined to be slipshod in treatment, anticipating failure 
of union, on account of age and less vigorous bones and on account 
of the fear of applying extension and splints with the immobilization 
they demand. Decubitus ulcers, a delayed pneumonia, or a hypo- 
static congestion of the lungs, have been considered first; hence, 
many cases of non-union or fibrous union are to be found. I have 
seen many femoral heads removed after five to eight weeks of such 
nondescript treatment because no union developed, and while func- 
tional results were fair after their removal, they probably would not 
be equal to a bony union to a retained head. Instances of impaction 
with shortening in adults, roentgenograms of which betray angularity 
and distinct line of fracture, on open operation within a few weeks 
after accident show bony union, not firm, but such as will later become 
firm. I have operated on several of these to obtain better length of 
the limb by means of the mechanical extension and various methods 
of fixation. Frangenheim^ found that the periosteal covering of the 
neck was very inactive osteogenetically and that when bony union 
followed fractures of the neck the callus arose in most part from 
the cancellous bone, complete ossification not following before one 
year. Absorption of this bone may occur even in impacted cases and 
is due, I believe, entirely to vascular disturbances from the throm- 
bosis of bloodvessels. If early motion is allowed or imperfect immob- 
ilization used, it is easy to believe that fresh sprouts of bloodvessels 
and osteoblastic columns from the cancellous bone become discouraged 
and fibrous or non-union takes place. At times also, a vigorous callus 
is thrust out and bony union inaugurated, but because of faulty treat- 
ment, too early weight-bearing, or imperative ambulatory care, before 
calcification of the new bone can follow, the use of the limb causes a 
retrograde process of absorption, and a fibrous union is the outcome. 
Instances are on record where the whole neck has been absorbed, leav- 
ing the head free and a false joint between it and the shaft. 

If all cases could be put in anatomical apposition and given a fair 
chance for bony union, there would be less complication of this phase 
of the fracture. For the reasons given and the exigences of imme- 
diate health, in a large number of cases anatomical reposition and 
retention are not faithfully sought. The fracture may not be recog- 
nized at all, and it can be truthfully said that the character of the 
repair is so varied and so unsatisfactory because an opportunity is 
not given to solicit bony union through the placing of the fragments 
in apposition. Cervical fractures take longer to heal than any others 
of the body. The necessity for use and movement of the hip and 
body in daily demands interferes seriously with correct repair, and 
the long stay in bed and confinement mitigate a happy result. 
The repair effort takes place in large part from the lower fragment, 
the upper fragment being able to do little more than hold its own 
viability because of its nutrition. To refer again to impaction, its 

1 Deutsch. Ztschr. f. Chir., 1906, Ixxxiii, 40. 



I 



FRACTURES OF THE UPPER END OF THE FEMUR 607 

value is twofold especially in elderly people. It absolutely holds the 
fragments in apposition. Treatment of the impacted cases is always 
of the most gentle sort with every regard 7iot to break it up, because 
observations shows that ununited fractures result in this region so 
frequently. As much care should be taken to bring unimpacted frag- 
ments into apposition as is taken to hold the impacted ends together, 
and better results will be observed. Murphy^ calls attention to the 
fact that fewer cases of femoral neck fractures would give poor results 
if they had been immobilized in abduction, or nailed, to obtain primary 
union without shortening or absorption, and believes that the friction 
of the neck on the head fragment where immobilization is short, 
imperfect, and followed by use, leads to ah absorption process. Evi- 
dence is shown in a case followed for two years and four months, of 
much absorption, the neck disappearing completely out to the shaft 
and only a small button of bone remaining in the acetabulum. This 
disappearance is largley a matter of blood supply and mobilization, 
for absorption in the epiphyseal area characteristically takes place 
from within outward. 

Ashhurst and NewelP traced 21 cases of fracture of the neck after 
three years and found that 62 per cent, of them had entirely useful 
limbs. Cotton^ says that non-union in fracture of the neck is not 
rare in cases showing impaction at first, as this frequently gives way 
and there follows some bone absorption, even if associated only with 
the repair process. Fracture in the trochanteric region almost invari- 
ably unites with bone, often with great deformity and disability there- 
from, whereas fracture higher up on the neck, if solidly impacted, 
unites with shortening and more or less deformity of eversion, giving 
fair clinical results. 

Imperfect impactions which tend to perpetuate the deformity 
give also fair results unless loosened. In loose fractures, which are 
really accidental incidences of non-impaction, there is no bony union, 
but a serviceable fibrous union often results. 

Unrecognized cases, contusions of the hip, and persistent limping 
and pain in children should be more carefully investigated and diag- 
nosed with the Roentgen rays as an adjunct used as freely as a white 
blood count is employed in intra-abdominal differentiations. Careful 
searching of dried plates of these cases will show many passed over 
fractures, and there will be less interstitial absorption of the neck 
anfl rarefying osteitis observed. When the neck is absorbed and 
use of the limb is made, pressure gradually forces the shaft up onto 
the dorsum ilii, and the body weight is carried by the Y-ligament 
with much pain and disturbance. Lane denies the existence of these 
conditions when anatomical approximation is made. 

After the base of tlie neck is broken and splits extend into the 
trochanteric area with separations and elevations of the periosteum, 

» Clinics of Dr. J. B. Murphy, ii, 10. 2 ^nn. of Surg., xlviii, 748. 

' Boston Med. and Surg. Jour., clxx, 719. 



608 FRACTURES OF THE FEMUR 

an abundant callus is found. The new bone fills in the areas'of blood- 
clot between the bone surface and the periosteum, or if the periosteum 
is torn, the bony outgrowth extends into the attached tendons and 
capsular structures. A large callus may thus form a buttress encircling 
the upper fragment and acetabulum, no union in the neck may be 
present, and yet the patient can support himself on the limb and 
walk comfortably. On the other hand, exostoses from this bone pro- 
liferation may extend in a. manner to restrict joint motion seriously, 
or by extension of a periarticular thickening of the joint structures, 
render walking painful and limit joint motion. One such case at Mercy 
Hospital gave on examination all findings of a completely ankylosed 
joint. Roentgenogram was not decisive, but seemed to show an 
exostosis which on open operation was discovered to interfere with 
joint motion and its removal without opening the joint capsule resulted 
in perfect freedom of motion in the hip. Advances in bone surgery, 
both in mechanical and operative treatment, are greatly reducing the 
percentage of absolute non-unions and improving final functional 
results beyond hope of former times. 

Repair may be further altered by constitutional disturbances or 
too prolonged treatment. In children excessive weight for extension 
may pull the trochanter below its normal level and increase Alsberg's 
angle so that a condition of coxa valga results, accommodated by a 
tipping of the pelvis when the patient becomes ambulatory. Many 
months — from four to ten — are needed for full bony consolidation of 
this fracture, and remeasurements can be made weekly after weight- 
bearing is started to make sure that the neck is not yielding, though 
function seems good and pain is absent. Premature use is thus to be 
checked by the use of a crutch for a few weeks and may ward off a 
later permanent shortening and deformity. If the hip-joint becomes 
the seat of low-grade arthritis or synovitis, the repair may terminate 
disastrously from a functional standpoint. Suppuration has been 
reported following hematogenous infection. Where the head is 
excised most cases result in shortening and stiffness in the joint caused 
by lack of support of the head and the periarticular changes. A new 
joint readily forms and fair function is enjoyed, but most cases do 
better with the establishment of a complete bony ankylosis from 
neck to pelvis which gives no motion but permits weight-bearing 
without pain. 

Signs and Symptoms. — These different types of fracture are con- . 
sidered together, as many of the symptoms and signs are common to 
both, varying in degree only. Attention should be paid to the patient's 
history, especially as to previous injuries to the hip or evidence of 
disease there or elsewhere that may influence fracture. Tuberculosis, 
carcinoma, and acute infections in any part of the body, bone cysts 
and other pathological influence, must be borne in mind as well as the 
immediate history of trauma and its nature. In elderly people and 
children the possibility of slight violence must be carefully brought 
out in questioning as it is frequently a cause. 



FRACTURES OF THE UPPER END OF THE FEMUR 609 

Local Trauma — Bruising and swelling of the injured hip are present 
when the cause is severe violence. These may be lacking entirely 
when the fall has been but a short distance and when the fracture 
followed a twisting or slip which was the real cause, the fall being 
secondary and checked by the patient's catching at a near-by 
support. 

Loss oj Fiuiciion. — This is the most striking finding of all, for while 
a severe contusion on the hip can for a short time cause loss of func- 
tion in the limb, it is rarely complete. In fracture in children, as stated, 
the loss of function may also be of short duration or entirely absent, 
so that they can walk away from the scene of injury. In adults or in 
old people this is rare indeed, and the limb is usually found slightly 
flexed and rotated outward and the patient can bear no weight on it 
nor raise it from the floor. Walker,^ in his 112 cases, found loss of 
function pronounced in 94, in but few of which could the heel be 
brought up toward the hip. Formerly differentiation between frac- 
tures near the head (intracapsular) and those near the base (extra- 
capsular) was built on the relative degree of loss of power. This 
method is liable to so many errors that it is valueless. Instances of 
patients being able to walk after fracture are recorded. Most prob- 
ably- impaction of firm enough character was present to permit it. 
By muscular action the patient may be able to flex the thigh on the 
trunk, but the knee flexes at the same time and the heel does not 
rise from the bed. Twice I have seen vigorous men with impacted 
fracture from direct violence who could raise the foot some six inches 
from the ground on supreme effort. Mr. Robert Jones has stated that 
the patient can often lift the leg from the bed in impacted fracture, 
and a correct diagnosis is only arrived at when spontaneous disimpac- 
tion occurs two or three weeks after the injury. In severe contusions, 
the limb may assume the position of fracture and be quite useless, 
but the disability is not so profound and a few days' delay, coupled 
with other findings, or the roentgenogram, will establish a diagnosis, 
(.'apsular distention from hemarthrosis cannot explain these cases, 
as the foot tends to assume the rotated inward position when the 
capsule is unrler slight pressure, as I have shown on the cadaver. 
Probably temporary' muscular paralysis allows the limb's weight to 
roll it out.- The position of the limb is quite characteristic. It lies 
>lightly flexed, abducted and rotated outward and is helpless. The 
foot may lie entirely on its outer surface because of gravity and relaxed 
muscles, and the angularity of the site of fracture. The posterior part 
of the neck being extracapsular and more fragile is more comminuted. 
A position of relaxation in resting is established with the toes turned 
>lightly out, anrl with the loss of the support of the femoral neck this 
position is exaggerated. In cases of impaction with the trauma 
P'ceived wlici) the leg is inverted the limb may not roll outward, but 

' Loc. fit. 

- Experiments hy Si>ee(l in J. H. Miirjjhy's fontrihuliori to Surgery, BDncs, .Jt»iti(s 
and Tendons, .Jour. Am. Med. As.sn., 1912, Iviii. 
39 



610 FRACTURES OF THE FEMUR 

remain in a normal position or be inverted. Inversion is very rare, 
and the slightest manipulation unlocking fragments will cause the 
foot to be everted. When little eversion is present, by grasping the 
foot on the normal and injured side at the same time, the surgeon 
may remark the degree of limitation of passive inversion on the frac- 
tured leg. The upper part of the thigh appears swollen and ecchy- 
motic, if a few days have elapsed since injury. Its fulness is more 
marked in fractures at the base of the neck. Shortening is apparent 
at a glance, even with the eversion taken into account, and it is made 
more noticeable by the fact that pain is constant, referred to the 
trochanter and upper surface of the thigh and can always be aggravated 
by passive motion. If the leg is supported in a comfortable position, 
this symptom is lacking, but very slight external movements or 
active attempts to move the limb cause its return, so that the patient 
is content to let it lie quietly. 

Measurements taken during push-and-pull traction on the leg will 
show a difference caused by lack of firm support at the neck when it 
is broken. 

Localized tenderness under pressure about the trochanter and hip 
is present. The examination by firm but pointed pressure on the groin 
will find a point of deep tenderness over the head. Slight jars on the 
heel or knee may discover great tenderness localized about the hip, 
but this is not very valuable evidence. 

Flattening of the hip, relaxation of fascia between the great tro- 
chanter and the iliac crest is also an observation of value. Comparison 
must be made with the body stripped and both hip regions exposed 
to good light. The evidence of these signs is permitted by the short- 
ening of the limb and the overriding of the fragments. 

Crepitus is an inconstant finding, and its absence has led to many 
diagnostic errors in this fracture. Impaction may account for its 
failure to appear; interposition of small pieces of periosteum or torn 
capsule or the overriding of the fragments also may, when the small area 
of the neck is considered and the tendency for the upper fragment 
to tilt forward are remembered. It is dangerous to attempt to elicit 
it for fear of destroying impaction or working into the site of fracture 
muscles and other soft parts from the pressure of the iliopsoas across the 
line of fracture with the leg in complete extension. In obscure cases 
where manipulation of the hip is painful and fracture is possible 
crepitus should not be sought. When placing an injured hip in a com-, 
Portable position or using very slight manipulation, the surgeon may 
Fortunately find crepitus, but it should not be searched for by exten- 
sive motions which are painful. Under anesthesia many cases believed 
to be impacted will give crepitus at the first gentle manipulation after 
relaxation. Gentle, steady extension with rotation enough to correct 
eversion will not often break up an impaction, but unguarded violent 
attempts of rotation of the limb will. The placing of the limb in a 
normal position by great gentleness with steady traction is quite 
harmless, and if it is sustained there by proper support there is less 



FRACTURES OF THE UPPER END OF THE FEMUR 611 

danger of further eversion and shortening and possible breaking up 
of unpaction. 

Shortening of the hmb and position of the greater trochanter are 
most important findings. Shortening varies from one-half inch to 
three inches, depending on the site of fracture, the force of the violence, 
presence or absence of impaction or overriding, and by alteration 
in the angle between neck and shaft. If the fracture lies near the 
head, in the early stage shortening is supposed to be little, increasing 
as the unopposed muscles, the recti, hamstrings, and tensor vaginae 
femoris act. When the fracture is near the base of the neck and 
o^-e^^iding is marked we should expect the maximum amount of 
shortening just after the injury, possibly growing less in a few hours 
when muscular spasm is lessened. Shortening may be small because 
of impaction, and suddenly or gradually become much greater when 
some untoward active or passive motion loosens the fragments.- 
Tritely, the exception — which may be a lengthening of the limb — 
proves the rule of the general finding of shortening (Walker, 70 in 
112, one-fourth to two inches). Shortening is indicated by displace- 
ment of the trochanter upward and is determined by the following 
measurements: First, the length of the limb as compared to its 
fellow member is to be ascertained. To decide this, bony points are 
selected as landmarks and pains are taken to place the limbs in a 
corresponding position in relation to the long axis of the body. If 
one leg lies parallel to the axis and the other is abducted, measure- 
ments will not correspond, so the limbs must be placed in symmetrical 
relation. A long stick or ruler is placed between the legs at right 
angles to another which joins the two anterior superior iliac spines, 
and each leg is placed to make an equal angle with this. If it is not 
desired to move the injured limb, although, as said, it does little harm 
to straighten the foot, the sound limb is moved out to make an 
equivalent angle. Palpation is then made to locate the anterior 
superior spines definitely, they are marked with ink or wet crayon, 
and the same markings are made on the tips of the internal malleolus 
and distances measured by steel tape (Fig. 417). In fat subjects it 
is sometimes difficult to locate the spines, or in the marking, the skin 
slides and the true point is lost. Practice enables one to become 
accurate. If a pendulous abdomen forbids use of the spines the um- 
l)ilicus can be used as an upper mark, but it is less accurate. It is not 
to be forgotten that limbs vary in length when no trauma or fracture 
is to be diagnosed. Either bone of each leg may vary so that the 
total length of limbs is equal. Bristow^ measured 128 cases of paired 
bones, 99 of which were femora, of which 78 per cent, were unequal. 
Wight,2 having concluded from observation that many uninjured 
limbs were of different lengths, measured 60 individuals with no 
fracture, turning the figures on the tape down so that they could not 
be seen and found equal length legs in only ten instances, the varia- 

» Ann. of Surg., 1, .313. 2 Arch. Clin. Surg., i, No. 8. 



012 



FRACTURES OF THE FEMUR 



tion reaching as high as one and three-eighths inches. This finding 
was later confirmed by 42 additional measurements. The attain- 
ment of precision in taking measurements is a matter of much 
practice, and even adepts will not agree in a series of cases measured 
independently. Bristow mentions a series of 312 measurements made 
by two men, in which their figures reached agreement in but 12 per 
cent. 

Position of the greater trochanter is of great importance. It is 
drawn upward by the iliopsoas, everted with the limb and drawn nearer 
to the middle line of the body and the anterior superior spine of the 
ilium by the adductors. To determine its position the following tests 
are helpful and quite accurate: Nelaton's line is one drawn from the 




Fig. 417. — Method of measuring leg length from fixed bony points. Note that the 
legs make equal angles with the long ruler placed between them, which lies at right angles 
to a cross piece joining the two iliac spines. 



anterior superior iliac spine to the most prominent part palpable of 
the ischial tuberosity. In fat subjects the latter point is rather difficult 
to locate, and the line is best obtained by finding this point, holding 
the fingers on it and extending to it a tape or string from the iliac 
spine. The line can be marked on the skin with ink or skin crayon 
and the position of the trochanter found. Normally this line strikes 
the trochanter just at its upper margin with the leg in the longitudinal 
body axis. If the bony mass of the trochanter extends above this 
line, shortening of the neck from fracture, or absorption change in 
this axis, or dislocation backward are present. 

Bryant's line and iliofemoral triangle are obtained as follows: The 
liml) is placed in a normal position if possible, the patient lying on a 



FRACTURES OF THE UPPER EXD OF THE FEMUR 613 

flat surface. From the anterior superior iliac spine a perpendicular 
is dropped to this surface (Fig. 418, a-c). A small wooden ruler or 
pointer acting admirably. The long axis of the femur extended 
upward b-c strikes this line, and the distance from the top of the tro- 
chanter to the perpendicular is measured on both limbs. In fractures 
the affected side Avill be found shorter (indicated by the dotted lines), 
the relative displacement upward of the trochanter being indicated 
by the difference in the limbs. 

Morris's bitrochanteric test is little used but is of value also. The 
observer marks the midline of the body and by holding his head 
directly over this measures the distance from the midline to the outer 
surface of each trochanter, either by tape or by a rule with a rider on 
each end. Shortening on the injured side is found in fractures of the 
neck and in hip dislocations, but the phenomenon of relaxation of the 
fascia lata between the ilium and trochanter is also a natural indica- 
tion of this shortening and requires no attempts at measurements, 
as it is plainly visible to the observer. When the fracture extends 



Fig. 418. — Diagram of Bryant's line and the iliofemoral triangle. The dotted line 
represents the displacement upward with consequent shortening of the base lino 
(Bryant.) 

into the trochanteric area and the trochanter is comminuted and 
flattened, it can be felt on palpation to be thickened from subsequent 
infiltration. This may allow a differentiation between fractures at 
the base of the neck and near the head where roentgenogram is not 
available. I believe that efforts to demonstrate a movement of the 
trochanter through a smaller arc or rotation of the limb where the 
neck is broken are valueless. Xo satisfactory determination can 
thus be made by palpation, and it is not worth the pain caused and 
the possibility of breaking up slight impaction in those cases in which 
this is needed. 

A false point of motion can sometimes be felt by the fingers of the 
hand grasping the trochanteric area, rotation of the leg being per- 
formed with the other hand, if the line of fracture is at the base of the 
neck and has allowed the shaft to be completely separated. 

Hennequin's sign is valuable. By digital compression below Pou- 
part's ligament outside of the great vessels, one may elicit pain and 
tenderness when the neck is broken or feel a bony mass nearer the 
surface than on the sound side. This is caused bv the rotation inward 



614 FRACTURES OF THE FEMUR 

and upward of the head fragment and the irregularity in the same 
direction of the broken neck. 

Diagnosis. — UncompHcated injuries to the hip region in elderly 
people caused by a trip or fall, in adults caused by crushings and 
other severe injuries incident to occupation, which give loss of func- 
tion in the limb with pain, eversion, shortening, and sometimes crepitus, 
are not difficult to diagnose. If the solution of the continuity of the 
neck is complete, it should not be difficult to diagnose, but if impac- 
tion has occurred during the application of fracture force so that 
slight shortening is found, no crepitus, and doubtful change in the 
position of the trochanter, more trouble is experienced in coming to 
a definite conclusion. All the points of diagnosis should be borne in 
mind, and in a fresh case with any doubt as to the presence of fracture 
no chances of error should be taken, but treatment should be that of 
fracture until one is satisfied to the contrary. More inexcusable errors 
have been committed by not following this advice than by treating 
suspected cases expectantly as fractures. Every surgeon may recall 
patients with neglected fractures in this area who have come to him 
months after injury limping on canes or crutches, who have never 
had any treatment directed toward fracture and whose legs were 
gradually becoming shorter. If shortening after trauma is demon- 
strated by careful comparison when other symptoms are positive, 
fracture should be diagnosed, even if a normal difference in limbs 
is considered. Partial loss of function only is found in some cases, but 
as given above, cases in children and elderly people must be watched 
and if possible subjected to the Roentgen rays for confirmation. Severe 
contusions of the hip followed by loss of power and eversion of the 
leg are not accompanied by elevation of the trochanter or other signs 
of fracture, crepitus is absent, and after a day or so of complete rest in 
bed function usually reappears rapidly. In elderly people no chance 
of error should be taken by the medical attendant. If the patient 
is allowed to bear weight on an undiagnosed fracture subsequent 
complications will surely follow, greatly lessening the patient's func- 
tional use and the attendant's reputation at the same time. When the 
case is not seen soon after injury the history should be carefully 
inquired into. Evidence of the immediate position and condition of 
the limb as observed by both the patient and others at the time of 
injury, the possible existence of former fracture not recognized, chronic 
arthritic changes, malignant tumors must be inquired into, and careful 
general examination should be persisted in. Careful measurements 
and manipulations should follow, and then in any doubtful cases the 
weight of evidence should be increased by the knowledge of many 
overlooked cases. 

Loss of function, a small amount of shortening, no crepitus, and a 
normal feeling trochanter would lead to a diagnosis of impacted 
fracture probably near the head. If shortening is great, crepitus 
present, and a thick painful trochanter is palpated, fracture through 
the base of the neck and complete separation can be expected. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 615 

Dislocation is not difficult to differentiate; the rigidity of the hmb, 
its usual adduction and flexed position ehminate that condition. 
In cases of anterior dislocation with e\'ersion of the limb the head 
can easily be felt under the pubic ramus; but if the head is on the 
dorsum of the ilium in backward dislocation the task is more difficult. 
In dislocation the absence of the head in the acetabulum may be felt, 
or the head can be made out on the ilium. Inversion in fracture is 
rare and may change into eversion, as explained, when the impaction 
or overriding are released by traction. 

Prognosis. — Prognosis depends on the age, treatment, and physical 
condition of the patient with the concurrent shock or additional 
injuries. If age alone is the greatest factor, it must be analyzed into 
the condition of the patient's circulatory apparatus and his reaction 
from shock. Each case has to be judged on the physical findings of 
the general condition in regard to immediate danger of life from hypo- 
static pneumonia, shock, or other complications. Fat patients with 
myocardial changes, those with chronic bronchitis, alcoholics, and 
others with greatly weakened general resistance usually succumb 
within a few days, exitus taking place in a mild febrile attack with 
or without delirium. In others of good habits and fair condition, 
death in four to six weeks is frequent, generally with an afebrile 
termination, gradual loss of strength, and pulmonary edema. Ashhurst 
and XewelP analyzed 58 cases with a mortality of 29.5 per cent., the 
end-results giving 62 per cent, useful limbs. Walker gave results in 
112 cases treated by the abduction method, 16 per cent, dying during 
treatment with end-results of 42 per cent, useful limbs. Ruth'^ claims 
100 per cent, bony unions through the Maxwell treatment with far 
less chance of the ordinary lung complications, because the patient 
can be put in a sitting posture and apposition of the fragments main- 
tained. 

While the immediate mortality is high up to the first six or eight 
weeks, if the condition of cure progresses to a stage to allow the 
patient to be up and about on crutches or in a splint, more bony 
unions are obtained than was formerly expected, especially under 
the modern treatment, both operative and simple. Cotton^ considers 
that an overregard for the patient's health may lead to an under- 
regard of treatment, and that most cases can be treated surgically 
and yet made comfortable. Results with shortening, eversion of the 
leg, and a limp are the rule. Restriction of the hip motion is incon- 
stant, depending on the degree of abduction with the change in the 
axis of the shaft and the periarticular changes which are caused by 
faulty reposition and immobilization, or the result of the individual's 
tendency. These people can get about quite comfortably, employing 
a cane and find little restriction to their activities already curtailed 
by age. They tire quickly, but soon learn to gauge their physical 
limit and are fairly content. Some hips remain constantly painful 

1 Ann. of Surg., 1908, xlviii, 748. 

* Loc. cit. • Loc. cit. 



616 FRACTURES OF THE FEMUR 

and give miicli arthritic pain even when the result is fair. Walker's 
statistics give LS deaths out of 112 cases, IV2 patients not found, 30 
unable to work because of persistent pain and restricted movement 
at the hip, usually because of shortening and abduction; 22 showed 
improvement and fair satisfaction. 

Fibrous union or non-union may be accompanied by good function 
and no pain. Murphy^ says that after fracture both fragments readily 
undergo absorption on account of the peculiar blood supply of the 
bone and the erosion of one fragment against the other, and that 
additional reasons for poor union can be found in the fact that this 
fracture is common in the aged, who have diminished osteogenesis. 
The bone after union under faulty conditions and position becomes 
subject to a severe strain at an oblique angle to its long axis, because 
though we can control the position of the distal fragment to a certain 
extent, we cannot control the head fragment, and approximation is 
very difficult. 

Conant^ cites 7 cases in which the results were bad in 2 and fatal 
in 1. He believes conservative treatment should be adopted for nine 
months before operation is considered and that close attention to the 
condition of the spica and its firmness in cases treated with immobiliza- 
tion in plaster will improve results. Operative results of fixation and 
removal of the head are given under Treatment. 

Treatment. — (1) Immediate treatment concerns itself with complica- 
tions and other injuries, shock, or transportation to a place of per- 
manent treatment. Fixing the leg to its fellow, after carefully straight- 
ening the eversion by bringing the foot into line, can be done by ban- 
dages or blanket splints covering both limbs. A Liston splint or any 
long padded board which will extend from axilla to heel is sufficient to 
ofter support by firm bandaging. In the aged, or when impaction is 
determined, no manipulation should be attempted until the findings 
have been carefully noted and analyzed. 

(2) Permanent non-operative treatment is usually directed along 
the following lines: (a) When age or other conditions threatening 
life are present, the first care is to preserve it. Prolonged immobiliza- 
tion or even a recumbent position may be contra-indicated, so that 
stimulants, sedatives and support in a reclining position are needed. 
The large ambulatory splints, either with felt pads or pneumatic cush- 
ions are useful in cases where the patient is able to carry them on 
crutches or with support, but, usually, feeble patients who really 
demand the ambulatory care, are unable to sustain the weight and 
restriction of these devices. These are put to bed well bolstered up, 
and sand-bags, rolls of blanket, and other supports are used to hold 
the limb in comfortable position. If impaction in these cases is present, 
it should be preserved. A little stronger class of patients will obtain 
this treatment and in addition can tolerate a Buck's extension and 
slight elevation of the foot of the bed to act as a counter-pull. Main- 

1 Ann. of Surg., 1903, p. 593. 

2 New York State Jour. Med., xiv, No. 3, p. 150. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 017 

tenance of personal cleanliness withont mncli pain, the nse of pads 
beneath the bnttocks to a^'oid decnbitns and a reasonable degree 
jof comfort and control of the wabbly limb are supplied by simple 
[support without much distress to the patient. Satisfactory func- 
"tional results follow this treatment in perhaps 30 per cent, of cases, 
but the mortality is high, and shortening always exists. 

{b) Continuous extension. If we lay aside this above-mentioned 
[class which represents really not a large percentage of the whole, 
the majority are to be cared for to obtain bony union if possible, 
and a minimum of shortening and displacement, for these two factors 
are the basis for future happy function. Some form of extension is 
indicated; on that point all agree. Its method of application and 
other expedients needed to have and hold apposition of fragments 
depend on the site of fracture. Buck's extension is excellent treatment 
if applied properly. This extension applied with well-fitting zinc 
oxide plaster on a carefully shaved limb is in much general use. 
Counter-extension should be provided for by the raising of the foot of 
the bed six to ten inches on blocks and the attachment by the pulley 
rope of a weight of ten to thirty pounds. The weight used has not 
been heavy enough in the past, and it should be increased so that a 
gradual, steady, and sure lengthening of the limb takes place until 
the trochanter is brought down to its proper level. It is impossible 
to apply extension and hold the leg in abduction at the. same time 
unless accessory splints are used because the patient shifts his posi- 
tion by tilting the pelvis. A perineal band for counter-extension is 
also advisable. But after application, if the weight is kept pulling and 
the spreader or the opposite foot do not get in contact with the end of 
the bed, the pelvis tilts a little toward the injured side and abduction 
in a measure is obtained. At least the adductor muscles are stretched 
and tightened and they act as a means of holding the fractured ends 
in contact. If control skiagrams are made after the treatment it can 
be ascertained that the neck lengthens slightly and assumes a better 
axis. Continuous extension by the Buck arrangement can be com- 
l)ined with the Hodgen splint, which is a gutter splint, suspended by 
wire or rope, raising the whole thigh and leg from the bed with the 
knee slightly flexed. By the fastening of the foot to the end of the 
splint some degree of extension can be obtained by its ow^n weight, 
or the Buck's extension may be added with the leg in this position. 

The long rigid Listen splint has little place in scientific treatment 
of fractures of the femoral cervix. It cannot, even with padding, 
be made to conform well to the curving chest wall, as it must do if 
it is to hold firmly; it allows for no extension if the leg is held straight 
by being strapped or bandaged to it, and it ties the patient down com- 
pletely to a flat position. As a temporary measure it is excellent; as 
scientific treatment it should be discarded. 

Anesthesia is rarely needed for correction of position to a simple 
upright position of the foot and a straight limb, but if mechanical 
extension is first to be applied by either human or instrumental agency, 



618 FRACTURES OF THE FEMUR 

anesthesia is indicated to relax muscles in order that impaction may 
be broken and an efficient reduction of fragments be secured. Ewald^ 
advises disimpaction in all cases where prolonged after-treatment 
is not likely to be followed by pulmonary complications. Stimson^ 
considers reduction of displacement essential to proper repair, but 
believes it is disadvantageous in fractures at the base of the neck 
with crushing into the trochanters, because an hiatus would exist 
between the fragments. This is particularly true when the posterior 
surface of the neck is more crushed or telescoped than the anterior 
and disimpaction might so separate the surfaces that no manipulation 
would ever bring them together. Treatment by breaking up of 
impaction followed by abduction is also advocated and was practised 
by Senn many years ago. He broke this up and then swung the leg 
in marked abduction, encasing both thighs and trunk in a plaster-of- 
Paris body cast. Embedded in this cast was a thumb-screw with a 
flat end which pressed on a pad placed over the trochanter, its support 
being assured by enclosure in the cast. By turning this up he could 
secure increased pressure later when the cast dried and loosened, or 
the parts within became shrunken, so that constant pressure was 
maintained against the trochanter to hold the neck against the broken- 
off head. Whitman and Walker also advocate the abduction treat- 
ment but without the forced pressure on the trochanter. This treat- 
ment aims to hold the fragments in contact and to give a union with 
the normal angulation of the long axis of the neck restored. When 
removed from the splint and brought down to a straight position 
the neck axis, being normal, overcomes a tendency to shortening. 
Although he likes the abduction method. Cotton^ criticizes it, inas- 
much as it is difficult to avoid letting the fragments slip past each other 
in the manipulation. This treatment requires the heavy body cast 
and is open to the objection of its weight and irksomeness and the 
helplessness of the patient, and though the results obtained are pos- 
sibly better than those with a Liston splint, with or without Buck's 
extension, or a simple Buck's extension, the confinement in the cast 
must be considered. Casts also will break or crack, the soft parts 
within will shrink, and looseness makes a reapplication necessary. 
This is tiresome, expensive, and may demand anesthesia. A single 
spica encasement of the thigh and body is also used but allows of no 
abduction to overcome angularity of the neck and no traction to 
provide for extension. To maintain abduction in one or both legs 
it is necessary to enclose one leg and the abdomen completely to 
fix the pelvic bones and the opposite thigh to the knee. If this is 
not done the lumbosacral spine curves around and no abduction is 
possible (Fig. 419). 

Two better and lighter methods of maintaining abduction and 
extension are found (Figs. 421, 422, and 423). The Thomas splint 

1 Wien. klin. Rundschau., September 19, 1909, p. 597. 
- Fractures and Dislocations, 1913. 
^ Am. Jour. Orthop. Surg., viii, No. 4. 



FRACTURES OF THE UPPER END OF THE FEMUR 619 

from the lower dorsal region to the heel is used on one or both legs. 
This splint is light, and by means of a perineal band of leather which 
is tightened to the rigid frame, extension is applied by Buck's, which 
can be fastened to a ratchet at the foot, ^iiiy degree of extension on 




Fig. 419. — A portable apparatus for mechanical extension of the leg. Satisfactory 
traction can be obtained by turning up the ratchet at an abduction angle which is held 
while a body plaster encasement is applied. 

the leg can be exerted. Abduction is also provided for. Jones, of 
Liverpool, uses this exclusively for fracture and operated cases in 
place of plaster of Paris, which I have seen him use only in the con- 
genital dislocation of the femur. It is a most serviceable splint, can 





•v.v 
Fig. 420. 



-Thomas's single hip splints. 



be made cheaply, and can be used many times over. It is surprising 
it is so seldom seen in America. 

The second splint, one which we use continuously at the County 
Hos])ital, Chicago, is the Rainey wooden splint (for which see Fig. 



1 



620 



FRACTURES OF THE FEMUR 



424). On this the patient rides comfortably and any desired degree 
of abduction of one or both Hmbs can be obtained. Simply through ^ 




Fig. 423 
Fig. 421. — Thomas's double hip spHnt for maintaining abduction and extension. 
Any angle can be obtained, and when used on a child, the child and apparatus can be 
picked up and moved at will. The Figs. 422 and 423 represent the Thomas hip splint 
for extension on the leg and a walking caliper with a heavy perineal pad. 

being bandaged to the splint the patient cannot turn over to one side 
or the other (Fig. 425). The abduction is fortified by extension on 
the injured side by means of a Buck's extension with the required 




Fig. 424.- 
of abduction 
pieces. 



-The Rainey wooden splint for immobilizing the hips in any degree 
Both side pieces held by metal clamps move in the slots of the cross 



weight from ten to thirty pounds, and the foot and leg can be bound 
into inversion without destroying the traction. Especially valuable 



, 



FRACTURES OF THE UPPER END OF THE FEMUR 621 

is this in operative cases, which may be dressed without disturbing 
the apparatus at all. Our routine non-operative treatment in cases 
which tolerate extension consists in this splint with suitable exten- 
sion to o^'ercome shortening and the proper angle of abduction and 
in\'ersion for five or six weeks, followed after that time, if bony union 




-Patient in bed on a Rainey splint. Note the fracture bed formed by the 
supporting board across the middle. 



is satisfactorily inaugurated, by a light plaster-of-Paris spica around 
abdomen and one leg to hold the position gained and protect the leg 
from possible refracture, the patient being allowed to get up on crutches 
an hour twice a day. After ten to fourteen weeks the plaster is removed 
and with a lift on the side of the uninjured foot so that no weight 




Fig. 426. — Suspension method for treating fractures of the femur in children. (Richter.) 



can be borne on the injured liip. Crutches are furnished and no 
weiglit is allowed for from five to seven months. 

The Philips-MaxwelP method of extension and counter extension 
fFig.420)'as described by lluth,^ is called by him the anatomical method. 



» Philips, Am. .Jour. Med. .Sci., Iviii, :V.)H. 



^ Loc. cit. 



622 FRACTURES OF THE FEMUR 

He reports over 100 cases so treated and claims bony union in all. 
Arguments advanced in its favor are as follows: 

(1) It overcomes displacing influence of muscular action. 

(2) It keeps all soft tissue from interference with union. 

(3) It uses the intact portion of the capsular ligament to maintain 
alignment. 

(4) It causes no pain. 

(5) It is applicable to all cases. 
This treatment is briefly : 

(1) The thigh is flexed at right angles to the trunk that the line of 
action of the psoas and iliacus may be brought above and away from 
contact with the anterior surface of the joint. 

(2) Outward pull on the upper end of the lower fragment is made 
by an assistant that the trochanter major may be brought out as 
prominently on the injured as on the uninjured side, while traction 
is made on the limb until all displacement is overcome. 

(3) The lateral pull on the upper end of the lower fragment is 
adjusted and steadied, and by Buck's extension and counter-extension 
to the limb in line with the trunk, normal length is maintained. 

(4) Adjustment of traction by pulleys and weights is made both 
in line of the body and laterally so that there shall be no tendency 
to shortening, eversion of the foot, flattening of the hip, or dropping 
of the greater trochanter below its normal level. 

The foot of the bed and the side corresponding to the injury, should 
be raised to counteract the body weight and to overcome the tendency 
of the patient to be drawn toward the lateral point of traction. As 
the upper fragment is passive, this adjustment continues whether 
the patient is flat or sitting up. This lateral pull is obtained by a 
weight adjusted on the side of the bed at the level of the anterior 
superior spine about ten inches above the mattress, connecting with 
a band of adhesive plaster four inches wide passed around the thigh 
high up and held open by a wooden spreader. To avoid pressure of 
the veins of the thigh a thick piece of saddler's felt is applied to the 
inner surface beneath the adhesive. The spreader, in addition to lead- 
ing to avoidance of venous pressure, also insures better inward rota- 
tion of the limb. This lateral traction rolls the femoral shaft in, 
pulls in the longitudinal axis of the neck, holds the fragments in 
contact, and puts the capsule on the stretch. 

Dyas^ has ingeniously modified this by placing a piece of 8 x 4 
scantling parallel to the side of the bed about two and a half feet 
above it, fastened at both the head and foot, and at a point opposite 
the anterior superior iliac spine by- nailing another 2x4 piece at 
right angles to the horizontal piece. A fracture bed is made, and 
the lower end of the perpendicular scantling is nailed to one of the 
boards to afford a rigid support for the pulley and lateral weight. 
This side bar can also be used by the patient to shift his position 

1 Railway Surg. Jour., April, 1914. 



t 



FRACTURES OF THE UPPER END OF THE FEMUR 623 

in bed and raise himself on to the bed pan. The lateral traction 
weight is about two-thirds as much as the longitudinal, i. e., from ten 
to sixteen pounds. The weights are greatest when the treatment is 
started, but as the muscles relax they are reduced. Every third day 
the knee is flexed with an assistant making traction in place of the 
weight removed. 

Cotton^ believes that all Ruth's cases were fractures at the base 
of the neck and that this treatment is decidedly non-anatomical for 
those near the head (intracapsular), as the lateral traction tends to 
separate the surfaces. If a true neck fracture has no real impaction 
or it has given way, the position is to be corrected, not through break- 
ing up the impaction loosely, but through remodeling it, this being 
accomplished by the abducted position and recourse to malleting. 

Operative Treatment. — Open operation is reserved for certain cases 
subject to the general conditions and restrictions expressed in the 
chapter on Operative Treatment, but broadly speaking to those cases 
in which the closed method fails. It should not increase immediate 
mortality, and it should prevent the unfavorable results of conserva- 
tive treatment, or the functional results of conservative treatment 
must be shown to be intolerable before all cases are operated on. 
Absence of union is difficult to determine before open operation; the 
following facts should be determined as an aid to belief: 

(1) Ability to push the trochanter upward. 

(2) Rotation of the trochanter in an arc smaller than that of the 
uninjured side (doubtful). 

(3) The relative position of the trochanter shown by two roent- 
genograms, one taken lying at ease, the other with force pushing 
upward on femur. 

Indications for operative treatment are: 

(1) Ununited loose fibrous union of at least ten weeks duration 
under conservative treatment, with loss of function, in those able to 
withstand operation. 

(2) Unrecognized and untreated cases with disability, cases which 
have been called sprains or dislocations. 

(3) ]\Iarked angular deformity and shortening in children and 
adolescents, conditions which lead to coxa vara and further shortening. 

(A) Fracture resulting in shortening and deformity in vigorous 
adults on whom extension has little eff'ect and cannot be maintained. 

(5) Cervical fractures complicated by dislocation of whole or part 
of the head. 

Methods. — (1) ^Artificial impaction as proposed by Cotton. ^ This, 
while really not an open method, involves anesthesia in nearly every 
case, and is put here for convenience. This method is used to "assist 
nature," and is based on the fact that the fracture leaves two surfaces 
of cancellous V)one with a cortical shell which can be brought into 
approximation and then be hammered together })y force applied on 

' Boston Med. and Surg. Jour., clxx, 718. 
2 Am. Jour. Orthop. Surg., viii, No. 4. 



024 FRACTURES OF THE FEMUR 

the trochanter. Under Hght anesthesia the leg is drawn down and 
crepitus obtained between the fragments; then a felt pad is placed 
over the trochanter on the injured side, counter-pressure is made on 
the opposite side of the pelvis, and half-dozen blows with a heavy 
wooden mallet are given over the trochanter in the direction of the 
neck axis. The leg is then tested to see if its tendency to shortening 
or eversion has been lost, or if the shaft rotates on the neck axis. 
If the impaction holds, the leg is put in a long side splint and traction 
is discontinued. This tries to do at one sitting what the Senn method 
hoped to accomplish by constant pressure. The original article cited 
two cases, the first in a man, sixty years old, who after a year had 
one-half to three-fourths inch shortening with slight eversion, but 
who could not raise his heel from the bed with leg in extension. The 
second was in a man, forty-eight years old, who obtained bony union 
with no shortening but with some rotation outward. The question 
arises in deeply impacted cases with shortening whether they could 
be loosely broken up and reimpacted by this method. 

(2) Open operation with simple replacement after freshening the 
fragments. Whitman^ reports an unrecognized case of neck fracture 
in which there was a fraction of an inch shortening with outward 
rotation and muscular fixation. This he opened, and found the head 
lying separately and behind the neck, but by rotating the limb inward, 
the fragments being held separated by a chisel, he was able to restore 
it to a normal position. Dowd (same page) reports a similar case in 
a ten year old girl treated three years before, in whom there existed 
after that time no shortening, but the roentgenogram showed depres- 
sion deformity of the femoral neck, a fact from which he concluded 
that this femur had apparently grown more than the other. Nothing 
was said as to the possibility of pelvic tipping. Albee also mentions 
such a case. 

(3) Open operation for nailing on the head with nails, or bone, or 
ivory pegs. Many instances of these operations are now in the litera- 
ture, and the relative value of just what material is to be used depends 
on the operator's choice and confidence in his asepsis. Originally 
this was Nicolayson's method, in which, without opening the site of 
fracture, he drove a nail through the trochanter into the head and on 
into the acetabulum to insure immobility. Various refinements have 
followed, directed toward assurance of alignment of the two frag- 
ments by exposure through the opened capsule, and there have been 
variations in the character of and method of insertion of the fixing 
agent. Cotton^ considers the nail a temporary fixation; so he leaves 
it projecting beyond the skin surface, removing it after three to six 
weeks. Dawbarn^ first pulls down the trochanter by a few days' 
Buck's extension; then, under local anesthesia of 0.5 per cent, cocaine 
in the skin and 0.2 to 0.1 per cent, in the deeper tissues, he incises 
with midpoint three inches below top of great trochanter. He drills 

* Ann. of Surg., xlvii. 2 Loc. cit. 

3 Ann. of Surg., xlvii, 120. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 625 

the femur through the cortex and then introduces a lono; steel trocar 
at an angle of 125 to 130 degrees slightly forward toward the head. 
Into this he passes a three-inch nail, the head of which he files off 
and drives on into the bone substance for an inch to become absorbed 
or encysted. In addition he injects arcund the nail tract a boiled 
solution of one-half each pure glycerin and glycerit tannine (U. S. P.) 
to promote callus formation. 

Technic of Open Operation. — Approach to the hip-joint is possible 
tlirough three incisions: 

(1) Anterior angular between the tensor vaginae femoris and the 
sartorius. This does not demand the cutting of any muscles, as there 
are none in front of the femoral neck except the iliacus, which is 
attached below to the lesser trochanter. Division of the fascia and 
deep separation brings the operator at once to the femoral neck but 
does not allow much room. 

(2) Posterior or Kocher incision behind the trochanter, which 
involves cutting the glutei muscles and the pyriformis. 

(3) Lateral U-shaped incision about the trochanter. After a flap 
of skin, fascia, and fat is reflected the greater trochanter with its 
attached muscles is removed by a Gigli saw and turned upward.^ 
This exposes the neck of the femur and the joint capsule. If the 
joint is not open the surgeon incises it, and by abducting and rotating 
the limb outward brings the fragments into view. The operator 
proceeds to examine the line of fracture, especially as to (a) viability 
of fragments, as determined by their color or by the scraping of the 
bone ends to obtain oozing of blood; (b) pseudarthrosis, or pieces of 
capsule between- (c) amount of bone absorption of the neck and 
feasibility of approximating the fragments. If the head is viable, or 
is to be fastened on as a transplant, necrotic but aseptic, the frac- 
tured edges are radically freshened and a long nail is driven through 
the trochanter into the' head with the leg held in abduction and 
mechanical extension. The joint capsule may then be closed by cat- 
gut and the trochanter attached to the femur again by a small nail, 
aufl the deep fascia and skin closed. If the head has been completely 
absorbed, the muscles attached to the trochanter are relieved of their 
insertion in accordance with ^Nlurphy's^ method, and four-fifths of 
the trochanter is cut off, reattached by nail to the head end of the 
neck, and placed in the cleaned-out acetabulum. This method is 
applicable to fracture dislocations with the head out of the acetabulum 
aiifl in an unusable condition. Fragments of joint capsule are trimmed 
oft* and removed from a position between fragments, and the limb is 
])ut up in abduction for ten to twelve weeks on a Rainey splint; 
not be be userl for six months. 

Fixation by pegs of autogenous bone, or by ivor\-, has been done 
with success. If there is not much absorption of the neck, and there 
is no objection to taking the tibial splint, this is the oi)eration of 

1 Murphy's Clinics, ii, 425. ' Ibid., p. 16. 

40 



()2G 



FRACTURES OF THE FEMUR 



choice, because no foreign body is left behind (Fig. 427). The tro- 
chanter can be sawed off or not — better not — and a suitable hole 
opened on the femur, a small tunnel dug down into the neck with a 
curette or reamer and the bone splint driven home as if it were a 
nail, the leg in abduction. Very careful subsequent handling is 
necessary to avoid breaking the peg. Immobilization should be about 
three months in abduction. Davison^ and others have reported opera- 
tions of this character. 

Suturing of the periosteum is not a useful procedure. Konig, quoted 
by Stimson,^ obtained one good result in five cases. If exposure 
sufficient to allow periosteal suture is made and this difficult task 
performed, it would be wiser to insure bony approximation by one of 
the fixation methods. Excision of the head with placing of the upper 




Fig. 427. — Fracture of the femur; operative repair by bone peg of fracture at the base 

of the neck. 

end of the femoral neck in the acetabulum is used in some cases, but 
many viable heads are removed, which if attached would become 
firmly united and give better function. To remove the head one 
has to free it from adhesions, cut the ligamentum teres, and then pry 
it out of the acetabulum, the cartilage being curetted out with a sharp 
spoon. The trochanter can be attached to the neck as a new head. 
When the fracture site is exposed, the head fragment is shown to 
have insufficient circulation by its yellowish color and smooth areas 
of friction on the neck. The centre may be deep yellow, and when 
curretted shows no oozing from the dry and friable bone, but around 
the edges of the torn capsular reflection some blue or red patches 



' Surg., Gynec. and Obst., June, 1914, p, 750; Jour. Am. Med. Assn., Ixii, 1551. 
2 Fractures and Dislocations, 1912, p. 353. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 027 

may persist, which indicate a shght blood supply. Generally the 
shaft fragment is a marked contrast in color and covering, apparently 
surrounded with well-nourished, bony granulations which bleed 
easily. Flint^ says : '' Excision (of the head) is to be preferred, because 
circulation has been demonstrated to be insufficient to favor union 
even after adequate approximation." 

In the aged when the fracture is near the head it is best to excise 
it within a few days if the general health permits. Patients will do 
better from early operation either with an ankylosed hip or a loose 
joint than with a long conservative treatment only to be subjected 
finally to open operation when unfit for it. Further indication for 
removal of the head is found in those instances of seeming bony union 
obtained by any means which in a few months after use show an 
abnormal joint accompanied by pain and disability or in which at the 
time of operation, fixation of the head is precluded on account of: 

(a) Extensive crushing or very jagged break of the neck. 

(6) Presence of cystic spaces containing reddish-brown material 
follo^"ing absorption of the cancellous bone from nutritive disturb- 
ance in those, either old or young, in whom a false joint has existed 
from six months to a year. These cases always permit upward dis- 
placement and rotation of the shaft w^ith absorption of the neck. 
The trochanter rests on the acetabulum and no fixation is of value, 
because the head is firmly fixed in the acetabulum and its cartilage is 
destroyed. As mentioned above, if the displacement were corrected 
to a normal position, there would exist an hiatus between the neck 
and head, especially on the posterior surface. Flint^ believes the 
trochanter should be tilted up by a linear osteotomy to allow the 
neck to fit into the acetabulum and the anterior edge of the acetabular 
margins cut away to avoid outward rotation of shaft. 

In fracture dislocations when the acetabulum has become filled 
with fibrous tissues these are removed before the reattached head is 
replaced, and the turned-in part of the capsule is attached to the 
margin of the acetabulum to prevent ankylosis.^ 

In operative cases which are fixed by mechanical internal splints 
I prefer to make roentgenograms of both hips from the same angle 
to be able to make the fixation at the same or an exaggerated angle 
on the injured side. These pictures assist in determining the direc- 
tion of the nail and the degree of abduction needed. Gerster^ states 
that intracapsular fractures in the young show best results when spiked. 

Instances in which capsular interposition obstructs union would 
never give firm attachment by any other than operative treatment, 
and if no union is started after eight to ten weeks in cases amenable 
to operation, they should receive the open treatment. Murphy^ 
calls renewed attention to this and the fact that there are three impor- 
tant elements in femoral neck fracture. 

' Ann. of 8ur{?., xlviii, 729. 2 Lqc^ cit. 

' Murphy's Clinics, ii, 425. ■* Am. Jour. Med. Sci., August, 1913. 

^ Clinics, i, 165. 



G28 



FRACTURES OF THE FEMUR 



(1) A tendency to shortening (which must be overcome by exten- 
sion) . 

(2) A rotation of the fragments. 

(3) A force to make continuous apposition of the fractured surfaces, 
which can only be obtained by abduction of both Hmbs. 

In naihng the head on the neck he advises using two nails inserted 
at difi'erent angles to avoid rotation of the head fragments (see Fig. 
428). 

Final Results after Operation. — (1) If fractures of the neck of the 
femur are successfully nailed or pegged with bony union there is a 
slight shortening and a lameness but a very useful and painless limb. 




Fig. 428. — Fracture of the neck nailed while the leg was under mechanical extension. 
The only fault in the operation lay in the projection of the nail points into the acetabular 
wall, leading to their removal, although aseptic nine months later. Some shortening 
of the leg followed, showing an incomplete bony union. 



(2) If operation is less satisfactory, union may be present, but 
there is also shortening, abduction, and rotation outward, so that 
function is impaired and a cane or crutch is needed (Fig. 429). 

(3) If a fibrous union follows and the operation has been a failure, 
the hip assumes a position such as found in non-union, accompanied 
by discomfort, pain, and shortening until the trochanter is finally 
displaced well upward on the ilium, held in check only by the 
Y-ligament. 

When the head is excised, effort should be made to obtain bony 
union to the pelvis, a condition giving shortening and lameness which 
are compensated for by the tip of the pelvis and the spinal curvature 
in the lumbar region. 



FRACTURES OF THE UPPER END OF THE FEMUR 629 

Fracture Through the Great Trochanter. — ^Kocher's Pertrochanteric 

Fracture. — This fracture, when clear dry roentgenograms of hip frac- 
tures are studied, is of more common occurrence than is usually 
belie\'ed. The head, neck, and greater trochanter form an upper 
fragment which remains in a normal position. The plane of fracture 
starts from the trochanter a short distance below its tip and passes 
obliquely downward and forward to the base of the neck, leaving the 
lesser trochanter attached to the shaft. This line may extend in a 
direct oblique plane from the front to the back of the bone, or be 
oblique in its anteroposterior plane, so that the opening of the frac- 




FiG. 429. — Fracture at the base of the neck through the trochanter nailed and 
screwed on. A good callus is evident. These are favorable cases for operative fixation. 



ture is higher in front than it is on the rear of the bone. The findings 
in these cases which I have studied divide themselves into three 
classes: 

(Ij The upper fragment of neck and greater trochanter may be 
jammed down into the oblique surface of the upper end of the shaft 
in an impaction with the strong calcar femorale, tending to penetrate 
into the softer tissues of the lower fragment. When we consider the 
driven-in appearance of the calcar femorale we cannot but conclude 
that the condition has been brought about by severe violence applied 
to the trochanter in general direction of the neck axis followed by a 



630 FRACTURES OF THE FEMUR 

yioldiiiii; in this oblique fasliiou of the trochanteric area and an imme- 
(hate adchiction of the hnib and h)wer fra^'inent. 

(2) The upper fragment may be sHghtly separated from the shaft 
with a simihir Hne of fracture, force having been received in the same 
manner as in (1) fohowed by immediate abduction of the hmb and 
lower fragment. 

(3) More marked examples of type 2 with separation at the lower 
angle of the fracture possibly involving a splitting off of the lesser 
trochanter and a slight impaction of the upper end of the lower frag- 
ment into the neck. These are very severe breaks occurring in young 
adults due to extreme violence and accompanied by shortening, 
abduction, and eversion of the leg. The separation is not great and 
thepseudo-impaction may not allow crepitus. The trochanter con- 
tinues to move with the shaft on gentle manipulation, but shortening 
is marked and the angulation forward of the base of the neck may 
be demonstrated, or at least the point of tenderness be definitely 
located by pressure. In complete separation the characteristic finding 
is absence of the movement of the greater trochanter with the shaft. 
Secondary cracks or splits may radiate into the femoral neck, the 
trochanter, or run down into the upper end of the shaft. One case 
here given as an illustration was compHcated by a fissure running 
down the shaft in such a manner as completely to dislodge a portion 
of its external surface. Extension treatment made no gain on the 
shortening, as the shaft fragment would not remain out in contact 
with the broken-off trochanteric area and abduction merely made 
this displacement worse. Open treatment was decided upon, and when 
the site was exposed the isolated fragment was found loose with all 
periosteal attachment destroyed. It was accordingly lifted out of 
the wound, split into two pieces by a chisel, and one piece used as an 
intramedullary splint. The upper end of this was driven well into 
the cancellous portion of the trochanteric area, as there is no medul- 
lary canal there, while the leg was adducted and flexed and the lower 
end slipped into the open medulla of the shaft, the procedure permitting 
a perfect replacement of the fragments with use of a portion of the 
fracture for repair. Subsequent handling was very cautious until 
the cast was applied, and a skiagram a week later showed perfect 
reposition. Inside of eleven days, however, the cast broke across the 
groin, the patient became unruly, and a slipping back into the original 
displacement took place in part. Though the final anatomical result 
was not perfect, the shortening did not exceed three-eighths of an inch 
and the function was extremely satisfactory. (See roentgenogram 
drawings and photographs, Figs. 453-456.) With little separation, 
the treatment is extension with the thigh either in slight flexion, in 
abduction, or in a straight line, according to the type of fracture. 

In instances of marked displacement or complicating fracture planes 
the subject of open operation will be carefully considered. These 
breaks cannot be plated, there is nothing above the line of fracture 
to which the plate can be attached, and the only thing which will 



FRACTURES OF THE UPPER END OF THE FEMUR 631 

hold, will be nails or screws, or wii'e, or such device as used in the case 
cited. Immobilization should be thorough and long-continued, at 
least three months, and great care should be used in allowing weight 
bearing, as the soft callus might give and permit much subsequent 
shortening. Excess callus, causing a lumpy mass, is a frequent result 
in these hips. 

Fracture of the Great Trochanter. — This fracture is infrequent and 
is caused either by direct violence received on the trochanter, or by 
muscular action accompanied by torsion of the whole limb inward. 
In the latter instance the plane of separation generally follows the 
epiphysis and the injury is in adolescents. The trochanter arises 
from a separate ossification centre and is really a point of attachment 




Fig. 430. 



-Fracture of the greater trochanter, the loosened fragment pulled upward 
and backward by muscular attachment. 



for the rotator muscles (Fig. 430). These tend to draw the detached 
trochanter backward and upward, but as it is rare for the periosteum to 
l)e torn for its full circumference, the separation is not, as a rule, great. 
In children the trochanter is found approximated to the pelvis and 
pulled backward so that satisfactory external rotation and abduction 
may be limited if it is allowed to heal in this position. Slight muscular 
strain or sudden overadduction and rotation inward may cause this 
trochanter to separate along its epiphyseal line in those children in 
whom a low-grade epiphysitis is present. The inflammatory reaction 
causes bone absorption and weakens the physical resistance of the 
epiphyseal area, and powerful muscular pull easily produces a separa- 
tion. This allows drainage of the inflammatory products into the 



632 



FRACTURES OF THE FEMUR 



siirroiinding tissues and causes hemorrhage and infiltration of fresh 
leukocytes with a curative result. Sprain fractures with pulling out 
of the periosteal insertion are clearly demonstrated by roentgenogram 
and demand diagnosis to be given treatment of rest until healed. 

Symptoms and Signs. — Symptoms and signs are pain on pressure 
over the trochanter, a little swelling and looseness of the fragment 
when the limb is rotated and separation is complete enough. Forced 
inward rotation of the thigh is painful and voluntary outward rotation 
is limited. In most instances locomotion is possible (Fig. 431). 




Fig. 431. — Incomplete fracture of the greater trochanter. The planes of separation 
are caused by the traction of the pulled-out muscles and direct violence. 



Treatment. — Treatment is by immobilization with a plaster dressing, 
the limb being abducted and rotated outward to favor apposition of 
the fragments. If the disability is great or if the separation at the 
epiphysis is marked and fear of lessened future function is held, the 
detached trochanter can be easily nailed on to the shaft through a 
very small skin incision, the limb being held in abduction and outward 
rotation during the operation. Subsequent immobilization need not 
be longer than four weeks. 

Fracture of the Lesser Trochanter. — Stimson states that 12 cases 
or specimens of this injury have been reported, 9 observed since 1908 
with the diagnostic help of roentgenograms. Most cases are found 



FRACTURES OF THE UPPER END OF THE FEMUR 



633 



in young people, generally boys, the fractiu*e occurring during the 
course of games or running when a sudden stop is made to avoid either 
falling or collision, or being caught. The psoas muscle is inserted into 
this trochanter and its powerful contraction causes a pulling-off of 
the bone fragment. In adults the fracture is caused by muscular 
action from severe strain or by a sudden misstep followed by a reflex 
contraction of this muscle. One case seen by the author in an adult 
man was caused by violent muscular exertion, in wrestling, with the 
leg pinioned by the opponent (Figs. 432, 433, and 434). In children loss 
of function may not be total, but nearly all the recorded cases in 
recent literature state that the children were conscious of a definite 




Fig. 432. — Fracture of the lesser trochanter caused by muscular action. 

time in their running when the accident occurred, and some were con- 
scious of a sudden snap in the thigh accompanied by pain. Few 
instances of fall on account of the fracture are recorded, and many 
were able to walk, sometimes to their homes. 

The common findings are pain on walking, pain or pressure over the 
lesser trochanter, free passive movement of hip in all directions with 
pain on complete extension. This pain may be cramp-like on standing 
and is relieved by the patient assuming a sitting posture. There 
is lack of active power to flex the thigh in most cases, but in some 
cases this power is present. The psoas muscle is inserted in the top 
of the lesser trochanter, and in case of avulsion of the bone its con- 
tractive power would be completely lost, but the iliacus, which is 



034 



FRACTURES OF THE FEMUR 



bound together with the psoas, takes a broader insertion, stretcliing 
out below the trochanter with some fibers inserted into the upper 
part of the hnea pectinea, so that if the psoas has completely lost 




Fig. 433. — Complete isolated separation of the lesser trochanter. 




Fig, 434. — Coniploto separation of the lesser trochanter with a wide separation of the 

fragment. 



FRACTVRES OF THE UPPER EXD OF THE FEMUR 



035 



power these fibers of the ihaciis may still be intact and produce 
voluntary flexion of the thigh. 

Localized swelling is not marked, but ecchymotic markings are 
apt to appear in a few days. In adults the limb is everted and looks 
like a fracture of the femoral neck, although shortening and other 
prominent findings are absent. 

Two additional signs are Vorshiitz's referred pain to the knee region 
and Ludloffsche's sign, which consists in an inability to cross the 




Fig, 43o. — Comminuted spiral fracture just below the trochanter. Note the overriding 
and separation of the lesser trochanter. 



legs, i. e., to throw the injured knee over the sound one. This latter 
sign also will fail if the iliacus insertion remains valid. Roentgeno- 
gram is necessary for positive diagnosis. 

Treatment. — Treatment consists in the placing of the patient in 
a sitting position in bed, the limb being supported in an upright 
or slightly inverted position by sandbags. Walbaum^ reports two 

' Deutsch, Ztschr. f. Chir., cxxviii, 130. 



636 



FRACTURES OF THE FEMUR 



cases in cliiklreii, both of whom recovered promptly with this treat- 
ment, one being- able to walk at once after ten days rest in this 
position, the other in twenty-three days with no subsequent trouble.^ 
Fractures of the Shaft of the Femur.— The shaft is the seat of all 
types of fracture and is frequently complicated by fractures through 
the greater trochanter and neck, through the lesser trochanter and 




Fio. 430. — Oblique fracture of the femoral shaft complicated by. an intertrochanteric 
fra(;ture. The intermediate fragment is not greatly displaced. 



through the lower end of the bone (Figs. 435, 436, and 437) . The bone 
can suffer multiple fracture, spiral breaks may extend from one end 
to the other, and comminutions of all degrees are found. 

Causes. — The causes of fracture of the shaft are direct and indirect 
violence and muscular action as detailed in the chapter on Etiology. 

» Deutsch. Ztschr. f. Chir., Bd. cxvii, S. 243; Deutsch. Ztschr. f. Chir., Bd. cxix, S. 557. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



637 



Pathology. — The type of fracture depends on the part of the shaft 
involved and is influenced by the normal curve of the bone, the mus- 
cular attacliments and the character and direction of the force. Hamil- 
ton says: "It is more common to find a transverse fracture in the 
middle third than at any other point of the shaft of the bone; but in 
the upper third the obliquity is extreme and almost constant." The 
obliquity in the upper portion is most marked in instances of indirect 
violence with torsion and muscular resistance, the lines of separation 
running outward and forward. Sharp direct violence at a right angle 
to the longitudinal axis will give a transverse fracture in the upper 




Fig. 



437. — .Spiral fracture of the shaft just below the trochanter extending up into the 
greater trochanter. One large fragment is nearly loosened. 



third. In the middle of the shaft transverse or slightly oblique planes 
occur on account of this area's being in a condition of muscular 
balance, while in the lower third the obliquity tends to run from behind 
forward and downward. 

Displacement is far greater than in fracture of any other bone, 
on account of the length of the femur and the powerful muscles con- 
cerned (Figs. 438 and 439). In transverse or very slightly oblique 
fractures where separation is complete the fragments override at once, 
and in very oblique fracture the sharp point of the upper fragment 
may penetrate the muscles and apj)ear at the skin surface, although 
indirect violence be the cause. Usually the lower fragment is drawn 



G38 



FRACTURES OF THE FEMUR 



upward and behind the upper one, on account of the muscular con- 
traction and infiltration of the thigh, and an angularity exists directed 
outward and forward (Figs. 440,441, and 442). The lower fragment 
rotates outward, turned by the weight of the foot and leg, and rarely 
turns inward. In upper third fractures the proximal fragment is, 
as a rule, pulled forward and outward by the muscles attached at the 
trochanters, the glutei and psoas, while the flexors and adductors 
draw the lower fragment inward and up against the upper fragment. 





Fig. 438. — A steep spiral fracture of 
the shaft just below the trochanter. Note 
the extreme obliquity of the plane of 
separation. 



Fig. 439. — Oblique comminuted 
fracture of the upper end of the shaft. 
Compressional violence aided by torsion 
the cause. Note the overriding. 



If the periosteum remains intact in one part of the fracture holding 
the fragment ends together, the shortening results from the angularity 
of the fragments; but if the periosteum is ripped off either fragment 
sufficiently to allow a slipping by, or is torn completely, shortening 
in addition to angularity is caused by the overriding. Rotation is 
present in all cases. 

The pathology of the complications is small in simple fracture, 
in spite of the opportunity for interposition of muscle and fascial 
fragments in the large thigh. Very rarely are vessels and nerves 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



639 



injui'ed except in. the lower third, where the vessels take a course 
directly behind the bone and can be injured immediately or suffer 
damage later from pressure or septic thrombosis. Gangrene of the 
extremity frequently follows. On account of the usual displacements 
and obliquities of the fragments little damage is done to these struc- 
tures even if the fracture is opened by penetration of the sharp points 
from within outward. Open fractures and gunshots of this bone lead 
to all the displacements and complicating pathology mentioned in 
the general chapter on Pathology (Fig. 443). 




Fig. 440 Fig. 441 Fig. 442 

Fig. 440. — Transverse fracture of the upper part of the femoral shaft. The displace- 
ment is marked and is difficult to reduce on account of muscular contraction. 

Fig. 441. — Oblique fracture of the upper part of the femur. Lower fragment drawn 
upward and backward. 

Fig. 442. — Spiral fracture of the upper part of the femur. The sharp points beconie 
imbedded in the muscles. 



Xon-union in simple fractures of the shaft treated conservatively is 
rare. Xon-union is frequent following operative interference if there 
is infection. IMathews^ records a case of a woman, aged fifty-one years, 
who twenty-three years before had sustained a simple fracture of the 
middle third of the femur (Figs. 444 and 445). This never united, 
probably on account of improper treatment, but after seven years 
she could get around quite well. At the time of the report she had no 
bony union between the fragments, which were freely movable, and 

' Ann. of Surg., li, 579. 



640 



FRACTURES OF THE FEMUR 



the leg presented a shortening of four inches. In spite of this she 
could walk a distance of five miles without aid and with no discom- 
fort. Delayed union of the shaft is also rare but malunions with 
deformities at all angles and much shortening are common. These 
are for the most part caused by faults of treatment or lack of coopera- 
tion of the patient with the attendant. In children malunions are 




Fig. 443 Fig. 444 

Fig. 443. — ^Spiral fracture of the upper part of the shaft. Marked shortening and 

rotation of the leg inward. 
-Fig. 444. — Non-union with angular deformity and great shortening in an adult 

man's femur. There seems to be considerable callus. After four months it was operated 

on. See following figure. 

liable to occur if the dressing used is not carefully watched and properly 
replaced when disarranged (Fig. 446). Adults who are ignorant, 
alcoholic, or otherwise unruly, by not cooperating, can ruin the very 
best effort made looking toward proper repair of shaft fracture. Judd^ 
details some interesting cases of this character. I recall one case at 
Mercy Hospital in which the patient tore off the plaster used for 



Railway Surg. Jour., 1914. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



641 



extension not less than four times for no other reason than that he 
did not Uke it and obtained a marked shortening and angular deformity 
as a result. 

Pain, effusion into the knee-joint, and later stiffness are found in 
about 60 per cent, of shaft fractures. Sprains received in the knee 
area with ligamentous tearing at the time of fracture, especially by 




Fig. 445 Fig. 446 

Fig. 44.5. — Operative repair of preceding non-union. The projecting screw was not. 

turned up becau.se the slot in the screw head failed to hold the driver. Perfect apposition 

and length. Plate now in leg ov-er three years with no irritation. 

Fig. 446. — Oblique fracture of the femoral shaft in a child. I am more in favor of 

treating this by coaptation splints and straight Buck's extension than by suspension at 

a right angle. It is almost impossible to overcome the effect of the limb's weight. 

indirect violence, explain many of these results; passive congestion 
from the obstructed circulation at the site of fracture or the pressure 
of extravasated blood between the fascial spaces account for most of 
the others which make their appearance within three or four days 
after the accident. Later effusions, both intra- and extra-articular, 
are probably brought a})out by the prolonged immobilization with 
sudden circulatory changes following passive motions or relief of spHnt 
41 



642 FRACTURES OF THE FEMUR 

and bandage pressure. Chronic periarticular changes with infiltra- 
tion and lack of muscle power may terminate in a permanently 
weakened and thickened joint with evidence of excess joint fluid present 
for years. Vigorous children and adults overcome this tendency in 
a few months. Aseptic aspiration with injection of glycerin formalin 
1 per cent, or simple strapping may cure this condition. 

Symptoms and Signs. — The symptoms and signs are loss of function, 
pain, deformity, false point of motion in the thigh, crepitus and 
shortening of the thigh. Unless the patient is thin it is very unsatis- 
factory to attempt to outline the bone continuity by palpation, but 
the complete loss of function with the foot lying turned over on one 
side or the other, the pain and apparent deformity, ev^n in fat subjects, 
make diagnosis sure. The length of the thigh or whole leg can be 
measured, as indicated in this chapter in the discussion of fractures 
of the neck, or if the shortening is to be strictly localized the measure- 
ments from the anterior superior spine to the lower border of the 
patellae can be computed. The position of the trochanter in its normal 
place will differentiate fractures of the neck or dislocation. Shortening 
may vary from a small fraction of an inch to four or five inches. 

Crepitus is inconstant and not worth searching for, unless it is 
accidentally demonstrated in the course of the examination. To 
determine the false point of motion in the thigh the attendant may 
find it sufficient to rotate the leg by grasping the foot, when he will 
discover that the trochanter does not turn with the shaft, or by plac- 
ing the flat hand beneath the thigh at the suspected point of fracture, 
holding down the upper part of the thigh and lifting, he can demon- 
strate the loss of continuity at once. Deep palpation avails little and 
is painful. 

Prognosis.— The prognosis in fracture of the shaft is of interest in 
three main directions : (1) First to be considered is danger to life, which 
is the most important, and is a serious question in open fractures 
especially. These are accompanied by much violence, shock, or 
hemorrhage, and this factor in the prognosis takes first place. Life 
may also be threatened in patients forced to lie in bed for the six 
or eight weeks of time needed for union where treatment is by 
extension or plaster casts, or in instances of refracture following 
falls upon patient's first starting to walk after healing. Ashhurst 
and Newell,^ in 26 cases of fracture of the shaft, had 5 deaths, caused 
by delirium tremens, pneumonia, and injuries elsewhere. 

(2) Next to be considered are good functional results alone. These 
are secured by bony union, generally with shortening and slight limp, 
compensated by the pelvic and spinal inclination. End-to-end or 
anatomical approximation is not necessary for the attainment of this 
result. Ashhurst and Newell studied 121 cases at the Episcopal Hos- 
pital, Philadelphia, to contrast conservative treatment with operative 
treatment, as they felt that the former had not received due attention 

1 Ann. of Surg., xlviii, 748. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 643 

in regard to functional result. Their end-results showed that only 
4 cases were completely incapacitated (all parts of the bone), while 
28 had perfect functional results with no limp or any hindrance to 
normal use of the limb, and of 41 examined for shortening, S showed 
normal length of limb. 

Good functional results are the rule after conservati^•e treatment; 
shortening always exists but may be very small and not noticed. 
Xon-union and excess callus — Estes found it in less than 10 per cent. — 
are not common. Following different methods of treatment I fre- 
quently find a large callus, which slowly absorbs in a few weeks and 
causes no interference with function or circulation. The only method 
by which one can be sure of no shortening is the open treatment. 
Those who assert they can obtain a normal or even longer leg than its 
fellow by continuous traction do not consider that much of this length 
is obtained at the time by ligamentous stretching at knee, hip, and 
ankle, and that it is not permanent. True end-results taken after the 
patient has used the limb in walking for three months give the final 
length, and the statement made above is made with this fact in mind 
and based on many cases. I have seen many examples of limbs giving 
the same length while one is in extension, or even when first out of the 
permanent dressing, which show decided shortening in a few weeks 
after walking was attempted. 

Of almost equal importance with preservation of proper length is 
the preservation of the weight-bearing axis of the leg, that is, the 
a\oidance of inversion or eversion of the foot which w^ould destroy 
the weight-bearing line, from anterior superior iliac spine through 
the patellar centre to a point between the great and second toes. 
Inversion is a better final result than eversion, as in the latter the 
weight-bearing line falls inside the great toe, and pronation of the 
foot, and strain on the internal lateral ligament of the ankle and knee 
follow with functional disturbance. 

(3) Finally good functional and satisfactory cosmetic results must 
be considered. People will desire to see the roentgenograms of their 
bone injuries and in addition to their functional result demand cos- 
metic results, that is good end-to-end reposition of the fragments 
without deviation of the angle of support. This is the ideal result to 
be sought; normal length is maintained and the patient does not 
have to learn new balancing habits or muscular tricks to get about. 

Estes' studiefl euvd-results in 760 cases, 700 of which were reported 
to make satisfactory recovery. 200 of these cases were checked by 
roentgenograms, but only 2 per cent, showed perfect restitution of 
fragments, except in the operated cases. An average shortening of 
three-fourths inch resulted, and this has been adopted more or less 
as a standard inrhcation of acceptable outcome. The axial displace- 
ment as indicated by in\'ersion or eversion of the foot was recorded 
in 463 cases, 370 of which showed no such displacement, so that our 

* Ann. of Surg., hi, 102. 



644 FRACTURES OF THE FEMUR 

prognosis should favor no deviation in three-fourths of the cases and 
not more than three-fourths inch shortening on the average. The 
average length of time in bed was 8.2 weeks; of subsequent use of 
crutch and cane eight weeks; the death rate was 3.69 per cent. 

Treatment. — Considering fractures of the shaft as either open or 
closed the treatment divides itself into: (1) the application of dress- 
ings and splints, including Liston splint, Buck's extension, Hodgen's 
splint (see Fig. 33, in chapter on Treatment) double inclined planes 
and railroad splints, Thomas and Rainey splints, ambulatory and plaster- 
of -Paris splints and casts; (2) operative treatment, including simple 
reposition, nailing. Lane plates, intramedullary bone and ivory splints, 
Steinmann's and Codivilla's nail extension and Ransohoff's modifi- 
cation with ice-tongs. The reader is referred to the remarks in the 
general chapter on Treatment and the previous remarks in this chapter 
on the Femur for details not given here. 

Immediate care in closed fractures is like that given fractures of 
the neck by lateral padded support or by simple fastening to the 




Fig. 447. — Nathan R. Smith anterior suspended spHnt for fracture of the femur. No 
enclosing bandages are shown on the Hmb. (Stimson.) 

fellow limb until the point of permanent treatment is reached. If 
alcoholic delirium, other grave injuries, unruly condition, or mental 
disturbance demand restraint, the Liston splint of padded wood 
extending from the axilla beyond the foot can be used until the con- 
dition improves. Buck's extension applied from a point below the 
site of fracture with a sufficient weight (fifteen to thirty pounds) can 
be used alone or in combination with the railroad splint, or the Hod- 
gen's gutter splint (Fig. 447). Anterior splints suspended from above 
and combined with traction are not favorites in general use. They 
are valuable, but the railroad or gutter splints are better. Double 
inclined planes can also be used, but are not comfortable, so that 
the patient often twists around, destroys the angle of the replaced 
fragments, and interferes with the result. Traction can be applied 
from a point below the site of fracture extending out beyond the knee 
to a pulley and weight; a smaller weight must be used on account of 
the limited area of attachment of the plaster on the thigh. The rail- 
road splint by its movability is to be preferred to the double inclined 



FRACTURES OF THE UPPER EXD OF THE FEMUR 645 

plane, as it takes up the patient's movements in part and with the 
leg horizontally extended permits a much heavier weight. Simple 
Buck's extension with the foot of the bed raised, aided by close-fitting, 
coaptation splints at the fracture site, make first-class traction and 
treatment until callus has formed. Slight abduction can be main- 
tained, and by careful watching the axis of weight bearing can be 
perfected. A suitable pad should be placed beneath the injured 
trochanter to avoid rotation outward of the upper fragment. Support 
of the body of the thigh in instances of swelling and contusion can 
be given by long, narrow sand-bags or an anterior moulded splint of 
plaster, and when inflammation subsides in a few days the coaptation 
splints can be applied. 

"When the fracture is high up on the shaft and the upper fragment 
is flexed, the railroad splint or the Hodgen's splint and extension 
are very comfortable and favor reposition of the broken ends of the 
bone (see chapter on Treatment). Prolonged traction pulls the 
fragments into line until shortening is largely overcome and the con- 
tusion effects at the site of fracture disappear. After four or five 
weeks the patient may be anesthetized and further reduction accom- 
plished by mechanical or assistant's traction and manipulation, after 
which a body cast of plaster of Paris will hold the position obtained. 
As before noted, the plaster spica will not maintain abduction of the 
leg, and if this is desired the cast must extend to the knee on the 
opposite side. If at the expiration of six weeks the plaster spica is 
apphed with the leg in good position, the patient can be permitted 
to get up and use crutches after the plaster is thoroughly dried and 
manifests no tendency to crack across the groin. A lift of three or 
four inches is put on the sole of the sound foot so that no weight can 
possibly be borne on the injured leg to cause shortening or break the cast. 

Plaster of Paris is not used for first dressings of thigh fractures, as 
it formerly was. It does not allow correction of shortening and is not 
needed to maintain position of the bone while the patient is in bed 
and is not enough protection to warrant the patient being up and 
about from the first. The tendency for body casts to crack across 
the groin can be counteracted by using many vertical layers of the 
V)andage across the abdomen or thigh or by incorporating laterally in 
the plaster a long piece of inch iron or steel rodding. 

The Rainey splint is applicable to many cases, especially when 
the upper fragment tends to rotate out. Buck's extension can be com- 
bined with it. The Thomas splint, as mentioned in fractures of the 
neck, is an excellent one, allowing extension and any degree of abduction 
and the correction of angular deformities at the site of fracture by the 
application of bandages or adhesive plaster. It is particularly useful 
with infants, even more so than the vertical extension, as it enables them 
to be picked up, splint and all, and carried about with no fear of dis- 
turbance of the fragments. In small children, up to an age of under- 
standing, the treatment most used is by vertical extension with the 
Buck arrangement and a suitable weight. If one leg alone is thus 



646 FRACTURES OF THE FEMUR 

suspended, the patient is inclined to twist about at all angles or sup- 
port himself by raising the body weight with the other leg flexed at 
the knee, and consequently both legs should be suspended with 
enough traction to elevate the buttocks slightly from the bed. This 
arrangement allows for care of the patient. Blair^ suggests that the 
position for infants in the treatment of complete flexion of the thigh 
on the abdomen should be maintained by a splint of galvanized steel 
made from a cardboard model. This looks like a large letter Z, is 
heavily padded and can be removed each day during the bath by 
the mere holding of the leg in complete flexion. Complete flexion 
of the thigh maintained by broad diaper or bandage is often very 
satisfactory in infants. 

Infants and small children are usually treated by suspension of 
the legs at a right angle to the body lying in bed. One or both legs may 
be elevated, held by Buck's extension attached to a rope and pulley. 
A longitudinal bar is erected over the crib or bed and the pulley is 
inserted in this — the weight hanging clear of the bed. Enough weight 
is applied to lift the buttock slightly from the bed surface. When the 
child is bathed or the toilet is attended to, the bed-pan can be slipped 
under easily because the weight takes up the slack in the relaxed 
rope and the bone fragments are not disturbed. Little patients who 
are not watched twist and turn about in the bed if only one leg is 
extended, so that both legs should be included in the dressing when 
there is no special attendant. 

Silver^ has combined the Bradford frame and extension in a very 
useful manner. The gas-pipe frame is made about four inches longer 
than the patient and a little wider than the shoulders; at a point 
opposite the hip- joint when the child lies inside the frame a T-connec- 
tion is tightly screwed into the pipe. To this connection is attached 
a piece of pipe long enough to reach about four inches above the 
suspended foot. An L-connection capped at the end furnishes the 
terminus for this projection. The canvas covering the frame is 
made from one piece, a hole being cut for the passage of the upright 
described. If the surgeon desires to suspend both legs the frame can 
be shorter, as it does not have to care for one leg lying extended, and 
the terminal piece of the upright is longer. 

Adhesive extension is applied to the leg, as in Buck's extension, and 
the ends of the straps are fastened to the transverse ternainal bar, so 
that the buttock of the affected side just clears the bed. The leg can 
be steadied by carrying the diaper around the upright piece or an 
adhesive strapping can be applied around the groin and the base of. 
the upright. Small coaptation splints can be used around the thigh 
if needed. The upright iron pipe protects the leg from accidents. 

After four weeks union is established, and the young children are 
put in a body plaster cast with the lift on the opposite foot and allowed 
to get around on crutches (Fig. 448). 

1 Surg., Gynec. and Obst., May, 1914, p. 645. 2 Ann. of Surg., xlix, 105. 



FRACTURES OF THE UPPER END OF THE FEMUR 647 

Spiral fractures, long, sharp fragments of which penetrate the muscles 
at any portion of the shaft, are difficult to replace and hold in position. 
Each case must be handled and manipulated in accordance with the 
findings of the displaced fragments, and roentgenogram to check the 
reposition is indicated. Anesthesia and manipulation may satisfy 
the surgeon that he has obtained bony contact and fan* reduction, 
but if any doubt exists, or the deformity cannot be reduced, this 
class of cases should be treated by open operation and careful align- 
ment. In the upper third the lower fragment is inclined to pull inward 
and upward and its sharp upper point extending toward the hip-joint, 
and slight torsion at the time of accident will frequently break off an 
outer third fragment. At the low^er extremity the sharp upper frag- 



^^ 



i 





Fig. 448. — The Englemann splint for primarj^ and secondary treatment of femur 
and leg fractures. Extension is supplied by the perineal band and the sharp points 
which fasten into the heel of the shoe. The splint's side rods are adjustable. 



ment is driven forward into the quadriceps extensor muscle and is 
separated from the lower fragment, which is pulled down by the gas- 
trocnemius and may tear the artery and vein. If the limb is cold or 
shows no circulation and gangrene threatens, open operation should 
be done at once, the condition of the artery determined, and the 
advisability of amputation decided upon. Fortunately these cases 
of bloodvessel injury are very rare, and early open operation to fix 
the fragments with careful after-treatment will save many limbs. 

When union is delayed beyond the usual ten or twelve weeks all 
constitutional disturbances should be inquired into, and corrected, 
and in addition the patient should be placed in a body cast and allowed 
to be up each day in order to aid the circulation in the limb, and to 



648 FRACTURES OF THE FEMUR 

bear a slight weight on the bone, but weight-bearing should be con- 
trolled by checking measurements on the length of the limb to avoid 
further shortening. Late union nearly always follows, and if operation 
is contra-indicated or refused union should not be despaired of for at 
least nine months. Non-union, except where there is great overriding, 
intervention of other tissues, or some dyscrasia, is rare and should 
be subjected to open replacement if no distinct reason against this 
step exists. 

Open fractures of the femur are always grave injuries, even when 
opened from within by a pointed fragment. Cases made open by the 
causative violence suffer much laceration of tissues and comminution 
of bone and frequently entail amputation. The injury to bloodvessels 
and nerves, danger of infection and deep-seated abscesses in the 
muscular and fascial planes are apparent, and drainage of the fleshy 
thigh is not easy to attain. The Lambotte method is excellent treat- 
ment for these open fractures. Lilienthal^ advises the fixation of the 
fragments by long-handled gimlets screwed into the bone remote from 
the site of fracture, reduction being made by two pieces of steel rod 
applied to the line of gimlets, the whole being bound together by 
plaster of Paris which has been previously sterilized by baking. The 
open wounds are carefully disinfected, and no sutures are used in the 
soft parts, but a packing is put in as if osteomyelitis already existed. 
After two or three weeks, the gimlets are removed, and the wound 
edges, now granulating, are brought together by adhesive plaster. 
This makes the procedure quite safe from the septic standpoint, will 
improve the functional result, and shortens convalescence. Other 
methods are given under Operative Treatment. 

Routine treatment as described in the chapter on General Treat- 
ment is the more conservative. A minimum of handling consistent 
with reduction of fragments within the soft parts, removal of foreign 
material and the control of hemorrhage followed by a copious absor- 
bent dressing with drainage is good practice. The limb can be cared 
for on a double inclined plane or a suspended Hodgen's splint. After 
danger of sepsis is past and the wound starts to close, the body plaster- 
of-Paris cast can be applied or extension with weight in attempt to 
overcome shortening. If malunion or great deformity results, open 
operation looking toward correction should be performed. 

Ambulatory splints — see chapter on Treatment. 

Operative Treatment. — Fractures of the shaft of the femur are most 
favorable for open treatment on account of the importance of this 
bone to the individual's activity, its relatively easy access without 
damage to the soft parts, the large size of the bone and the ease with 
which strong traction and manipulation can be applied. Estes,^ in 
his canvas of the American Surgical Association, found that only 
four out of thirty-five surgeons were opposed to open operation in 
any case, and thirty advocated it only in case evident proper restitu- 

1 Ann. of Surg., 1912. 2 Loc_ gi^. 



FRACTVRES OF THE UPPER EXD OF THE FEMUR 



649 



tion had not been accomplished. He names the following five diffi- 
cnlties hard to overcome unless operation is undertaken : 

(1) INIuscular spasm, which was overcome by anesthesia. 

(2) Locking of fragments by leverage or g^a^'ity. 

(3) Interposition of fascia, muscles, etc. 

(4) Persistence of shortening even after the muscular spasm is 
overcome. 




Fig. 449. — A spiral fracture of the 
femur which extended 9 inches. 
After the first large plate was ad- 
justed a second smaller plate was 
used to bridge over the fracture 
plane to give added strength. The 
result was excellent with no short- 
•ning. 



Fig. 450. — An example of unfortunate result 
in plating. The operator selected a patient 
on whom it is unwise to place a Lafie plate, 
a young child. The plate was not strong 
enough and the bone became infected. Note 
the deformity of the leg, the screw tracts from 
which the screws have pulled and the bulging 
plate presenting just beneath the skin. 



(5) Preservation of reposition of fragments until a fixed supporting 
dressing is applied. Anatomical reposition, the criterion of cosmetic 
result, is not oV)tained in more than 1 or 2 per cent, without open 
operation. But the dangers of operation by other than those skilled 
ill this work are to be pondered in every case in addition to the argu- 
ments given in the chapter on Operative Treatment. 



650 



FRACTURES OF THE FEMUR 



Tcchnic. — x\pproach from tlie lateral aspect of the thigh by a long 
incision in the axis of the femur gives quick and complete exposure 
of the fracture at any site from the greater trochanter to the knee. If 




II 



Fig. 451. — Another unfortunate 
example of plating plus wiring. The 
anatomical result good. The great 
hypertrophied mass of bone is the 
result of the infection. I imagine this 
plate was put on beneath the peri- 
osteum which was raised and then 
sutured over. 



Fig. 452. — Faulty result after plat- 
ing caused by conditions beyond con- 
trol. After operation this case was 
in perfect alignment. He was left in 
other hands and the cast was removed 
too soon. The plate had to take up the 
strain of weight-bearing and while it 
held in its attachment to the bone it 
bent slightly. An aseptic result. 



a Lane plate is the choice of fixation and much overriding is present, 
the patient should be placed on the pelvic rest and extension from 
the ankle with some mechanical apparatus provided for before the 
incision is made. The fragments are isolated as in the fracture of the 



I 



FRACTURES OF THE UPPER END OF THE FEMUR 651 

humerus and by manipulation and traction are brought into ahgn- 
ment. Oblique fractures are to be aligned and clamped in position 
while a plate is affixed or a wire is thrown around. I do not believe 
wire has any place in the treatment of fractures of the shafts of long 
bones; it will not hold any tension nor does it immobilize the frag- 
ments. It has a use in holding on detached fragments that cannot be 
included imder a plate. Long plates, sometimes two, are needed to 
hold oblique fractures (Figs. 449, 450, 451, and 452). Nails are not 
of much service in fractures of the shaft, unless the break is oblique 
or small fragments are attached. In cases with much deformity and 
callus formation they are of use when a plate cannot be applied or 
infection exists in the bone.^ In transverse fracture use of the intra- 




FiG. 453. — Repair of a transverse fracture of the shaft by an intramedullary splint 
fashioned from a fragment of bone found loose in the fracture site. Note the deficiency 
in the outer part of the shaft caused by removal of the loose piece. 



medullary splint is the best and easiest treatment, as it can be done 
quicker and through a smaller incision and gives absolute anatomical 
reposition with less disturbance of the parts than any other method 
(Figs. 453, 4.54, 455, and 456). Simple reposition may be sufficient 
where the fragments are of such a nature that they can be locked 
together and where possibility of their slipping out of place while the 
external dressing is being applied is remote (Figs. 457 and 458). After 
plating, a firm body cast is indicated with the limb in a position 
favoring the least strain on the internal splint. After intramedullary 
splinting either a cast or a Thomas or Rainey splint can be used, but 
always some secure external support is needed. 

' Murphy, Clinics, i, 853. 



652 



FRACTURES OF THE FEMUR 



Cases of malunioii or delayed union demand freshening of the site 
of fracture, reniovtd of excess calhis and reaming of the medullary 
cavity if an intramedullary splint is used. External splints in these 
cases should be left on half again as long as in ordinary cases, that is, 
from twelve to fourteen weeks. 

Accessory instruments for the approximation of the fractured ends 
have been described by Gerster. He used a bicycle chain with a hook 
or turnbuckle to spread the ends apart that they might be brought 
into alignment. Edward Martin has suggested the use of a stout 
piece of sterilized muslin fitted cap-like over the upper end of the 
lower fragment, on which traction can be made and the bone brought 




Fig. 454. — In handling the patient the postoperative cast was broken and the 
bone peg sUpped and permitted overriding. A longer bone peg would not have allowed 
this, but might have broken (see Fig. 488). 



into alignment. These devices introduce more material into the open 
wound and give more chance of infection. The more modern means 
of mechanical extension applied from the foot or leg, or the device 
of turning the bone ends out from the wound for inserting the intra- 
medullary plants are simple, more efficient, and cleaner than these. 
Cases with three or four inches shortening have been brought into 
alignment with ease by the author without the use of these methods 
of extension and by intramedullary splinting. Lambotte's method 
(refer to chapter on Operative Treatment) has been little used in 
America, but bids fair to be popular and useful in open fractures, 
^lurphy,^ reporting a case of infected open fracture just above the 

1 Chnics, ii, 617. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



653 



condyles with non-union and overriding of the patella by the lower 
end of the upper fragment, made use of two phosphor bronze plates 
implanted at right angles into the two fragments in slots made with 
a rotatory saw. The upper fragment was resected one and three- 
quarters inches and the lower fragment squared off to meet it. Good 
apposition with union and 10 degrees voluntary motion in the knee 
was obtained after nine weeks. 




Fig. 455. — Final result of the operation illu.strated in the two preceding roentgeno- 
grams. There is no apparent deformity, and shortening is about | inch. The board end 
placed under the injured heel exactly overcomes the shortening. 

There are other methods which are really operative in character 
and which do not open the site of fracture: 

(1) In Codivilla's nail method a nail is driven through the os calcis 
and to it extension is a])})licd directly to draw out the femoral or leg 
fragments. Josserand, Pvcudel, and Micheh re])()rt 4 cases treated 
in this manner. The ages varied from six to fourteen years and the 
amount of weight used from 8 to 15 kg. One case was described as 

' Kevue d'Orthop., Novcnihier, 1013. 



G54 



FRACTURES OF THE FEMUR 



a perfect recovery. All showed 1 cm. shortening, 2 bowing of the 
femur and 3 pulling of the nail through the os calcis so that it was 
held by the plantar tissue alone. Case 3 showed some loss of bony 
tissue in the os calcis after the nail pulled through, together with 
two small exostoses. 

(2) Steinmann's nail extention method^ has been tried out by 
Gerster, Bartlett, and myself in America.^ 



i 






ll 




i 


1 




^ 


1 


BF^ Mr--.»-<;^-^ 


—————— —^ 



Fig. 456. 



-Side view of the patient shown in the preceding figure. Note the amount of 
voluntary flexion and the faint operative scar on the thigh. 



Technic. — A drill or nail eight inches long and about 4 mm. in 
diameter is inserted horizontally about a half-inch above the external 
condyle of the femur by the operator first pulling the skin upward, 
the nail penetrating clear through the thigh. Iodine, desiccating 
powder, and collodion are put over the points of exit, and gauze trans- 
fixed over the ends completes the aseptic dressing. To avoid rotation 
of the leg one end of the nail, generally the outer, can be supported 



' Zentralbl. f. Chir., 1907, p. 938. 



Am. Jour. Med. Sci., August, 1913. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



655 



by a wire from a bar above the patient. The main extension with a 
weight of eighteen to twenty pounds is in direction of the longitudinal 
axis of the thigh and is obtained by wires or tongs applied to the 
ends of the nails, which project an inch or more beyond the skin. 
The thigh is maintained in semiflexion and the heel is not allowed to 
touch the bed. In its insertion the nail should avoid the medullary 
canal, the hematoma at the site of fracture, the joint capsule, and the 
epiphyseal line; hence it is placed, as mentioned, just behind the middle 
line of the bone. When the fracture site is in the lower third of the 





Fig. 457. — A case of refraction following 
operative repair by intramedullary .splint. There 
seems to be sufficient callus. Fracture passed 
squarely through the bone peg dispro\nng any 
weakness on its part but pro\dng the action of a 
force which refractured in spite of its presence. 



Fig. 458. — Repair of a 
transverse femoral shaft frac- 
ture by an intramedullary 
peg. 



femur the nail is inserted through the upper end of the tibia about 
one and a half inches below the joint surface. By this extension, which 
needs to be greater in old than in recent cases, and in which less weight 
is needed than in other methods and yet more weight can be used, the 
traction is continuous and painless when once in position. Steinmann 
asserts that through it the fragments can be better controlled than by 
any other means except open operation, that shortening is usually 
overcome in one week, and that no cases of delaj^ed union have ever 
resulted from its use. Passive and active motion is used within five 
days after the extension is applied, and there are none of the later 



650 FRACTURES OF THE FEMUR 

knee disturbances caused by stretching of the Hgaments. The exten- 
sion should never be used for more than five weeks, the usual period 
being three weeks. To remove the nail, the operator paints one end 
with iodine, then grasps the other, rotates it to loosen it and pulls it 
through. Iodine being squirted into the holes and a dressing applied, the 
wounds heal promptly within a week. Some cases run a fever from 
1 to 1| degrees while the nail is in position. If the lower fragment is 
displaced posteriorly, it can be supported further by extension to the 
thigh at right angles from above, but Jones believes that in this 
deformity after fracture, extension in the long axis ultimately brings 
the fragments into line. 

As the limb straightens out and lengthens, if the weight becomes 
irksome, it can be released for a few hours and then reapplied, but a 
condition of extreme lengthening, possibly 1 cm. more than the well 
thigh, is to be attained; when callus is well established, the extension 
is removed in three or four weeks and a moulded plaster or Steinmann's 
hip splint, with the upper margin encircling the thigh and resting on 
the pelvis and the lower end impinging on the nails, is used. 

The greatest objection to this method is the possibility of infection 
in the nail wound. This would occur shortly after insertion or three 
or four weeks later, and while it is relatively easy to put the nail in 
aseptically, it is not so easy to maintain it so. However, all of Gerster's 
infections have remained localized, and no fatal cases are reported 
where Steinmann's technic is adhered to. One fatal case has been 
recorded in which the hematoma about the fracture was entered, and 
thus an open fracture really made. Shortening of as much as 11 cm. 
has by this method been overcome and in cases of as long as forty 
days' standing. In malunion with overriding .open operation can be 
done to free the bone ends and the nail extension then applied, but if 
one takes the risk and trouble to open the fracture, it is the author's 
opinion that extension can be procured by mechanical means and a 
plate, or intramedullary splint, used at once. Gerster reports 11 
cases which do not seem to offer any better results than those handled 
by other treatments and not so good as those treated by use of the 
internal splint. 

(3) The nail extension method has been modified by the use of 
ice-tongs driven into the femur with extension applied to the handles. 
Ransohoff^ reported 3 cases treated by this method after he learned 
that 2 out of 13 cases of fractured femur plated at the St. Louis City 
Hospital died. This apparatus is applied and used like the Steinmann. 

Supra- and Intercondyloid Fractures. — ^These are described together,, 
as they are so frequently associated. The plane of fracture may be at 
any height above the condyles and be transverse or oblique, much 
as in the case of the humerus above the elbow-joint. The main frac- 
ture through the shaft is generally oblique from behind downward 
and forward, and the separation may be little or very great with the 

1 Trans. Arnei*. Surg. Assn., 1912, xxx. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 



()5/ 



upper fragment driven down toward the knee, the lower fragment 
riding upward and posteriori}', pulled by the gastrocnemius into a 
position of flexion (Figs. 459, 460, and 461). In addition to this simple 
displacement the lower fragment may suffer a split through its sub- 
stance in the intercondyloid notch. This split may be but a line, or 
the separation may be complete and extensive, so that the two parts 
of the lower fragment are spread laterally, the point of the upper 
fragment extending down between them, holding them apart. The 





Fig. 459. — Oblique supra- 
'ondylar fracture of the femur 
with e\-idence of fracture by 
direct ^•iolence on the internal 
condyle. There is considerable 
overriding and the patella 
seems to lie very high on that 
account. 



Fig. 460. — Healed transverse supracondylar 
fracture \\nth deformity. Note arthritic change in- 
vohdng the patella and tibia. 



patella sinks into this separation, if the hiatus is wide enough, and if 
the crucial ligaments are torn, a subluxation of the tibia backward on 
the lower fragment exists (Figs. 462 and 463). As the support above 
the knee is lost, the leg can be twisted or rotated to either side, and 
great deformity, shortening, and displacement of all fragments are 
found. If the cause has been a fall from a height with the patient 
striking on the knees, rather than direct violence with twisting, the 
sharp lower end of the shaft fragment penetrates the muscles and 
skin anteriorly and causes an open fracture. Or, as mentioned, this 
42 



()58 



FRACTURES OF THE FEMUR 



fragment bursts into the subcrural pouch of the knee-joint, opens 
the joint widely, and comes to rest against the patella or the upper 
surface of the tibia. 

Additional pathology concerns the joint and the vessels. The joint 
always becomes swollen and distended even though not penetrated, 
or though the lower fragment is not split. The effusion into it in severe 
injuries is pure blood; in milder cases the transfusion takes the 




Fig. 461.- 



-Spiral supracondylar fracture. Point of the upper fragment driven down 
into the joint and against the patella. 



character of serum or excess normal joint fluid. The joint findings 
gradually subside if no infection follows or the fracture is not open, 
leaving a thickened capsule which may shrink and cause limitation 
of motion or a distended weakened joint. The popliteal vessels if 
ruptured lead to great effusion of blood around the knee, especially 
on the posterior aspect, but this hematoma may burrow up into the 
thigh and by pressure or loss of vessel continuity threaten gangrene 
of the leg. Rupture of smaller branches of the anastomatic arteries 



FRACTURES OF THE UPPER END OF THE FEMUR 659 

causes smaller and more delayed hemorrhage, which may give as great 
circulatory interference. 

If healing follows uncorrected displacements of this character, the 
knee is generally quite stiff, the thigh shortened, the leg in flexion 
and much permanent thickening and deformity about the knee 
remains. 





Fig. 462. — A similar spiral supra- and 
intercondylar fracture entering into the 
knee-joint. Note the comminution and 
overriding. 



Fig. 463. — Healed fracture just 
above the condyles with deformity. 
Note the apparent anterior disloca- 
tion of the knee. 



Diagnosis. — Diagnosis is not difficult. The thigh from anterior 
superior spine to lower patellar border is short. There is great swell- 
ing of the knee and a floating patella, if it has not been caught between 
two fragments of the lower femoral end, and there is independent 
movement of the condyles when they are grasped and m()})ilized, or 
severe pain while they are pressed together. If the ends are impacted, 
no crepitus can be felt, but the deformity is very apparent. Differen- 
tial diagnosis must inchule acute traumatic arthrosis or hemarthrosis, 
subluxation of the knee due to laceration of the crucial ligaments or 



()()() FRACTURES OF THE FEMUR 

fracture of the tibial spine, epiphyseal separation, and fracture of 
one condyle. Epiphyseal separations are found in younger people and 
are most often caused by twisting violence. Fracture of one condyle 
gives a rotatory displacement of the leg with a pseudodislocation at 
the knee and joint injuries, especially crucial ligament tears, which 
are described later under Tibial Injuries. 

Prognosis. — The prognosis regarding full functional return is poor. 
The danger to life is often great and the possibility of amputation of 
the leg present in 10 per cent, of the cases. However, it is now better 
understood that these fractures, as well as those following in this 
chapter, are less influenced in prognosis than formerly, considered by 
the fact that they invade the largest joint in the body. Surgical 
means of caring for them disregard the joint phase of the problem 
much more than was formerly considered possible. Blake^ records 20 
cases of supracondyloid fracture, 2 of which were open. He believes 
that excepting sepsis, the greatest complications are the difficulty of 
maintaining reduction and the greater limitation of motion after 
union. 

Treatment. — Simple treatment consists of reduction under anes- 
thesia by direct, extension, or extension and manipulation of the 
supracondylar fragments, the leg being held in flexion. This can 
rarely be maintained satisfactorily, and it is very risky to put on a 
circular cast when subsequent swelling about the knee is anticipated. 
Consequently a double inclined plane or the Hodgen's suspended 
splint are favorite treatments. In the double inclined plane exten- 
sion can be applied with the leg in flexion, not so much force being 
needed as in fractures higher up. Moulded splints or casts applied 
after the reaction has subsided and kept on until the fragments are 
strongly united and motion of the knee-joint is painless are good 
treatment w^here satisfactory reduction can be made or operative 
interference is not permitted. 

Operative Treatment. — Operative treatment may be demanded by 
the complications at the time of fracture. Laceration of the popliteal 
vessels may demand ligature or amputation, if both vein and artery 
are destroyed. In great displacement early operation offers hope 
of better ultimate function, provided good reduction can be accom- 
plished. Other indications for open operation are the danger of union 
which will be weak and lead to impaired function, marked and per- 
sistent deformity, including shortening, spreading of the condyles, 
or their rotation backward. 

Access to the site of fracture is obtained by lateral incision on the 
outer aspect of the thigh followed by retraction of the hamstring 
tendons and careful dissection close to the bone. The joint surfaces 
need seldom be entered. The fragments are exposed, the vessels 
identified and cared for if necessary, and by extension and manipula- 
tion of the leg under th^ ^ye the fragments can be brought into 

' Ann. of Surg., Iviii, 27. 



FRACTURES OF THE UPPER END OF THE FEMUR 661 



alignment and held by a plate, or wire, or nail. Blake^ treated 5 out 
of 20 cases by open operation: 1 was wired, 1 lower fragment was 
pried into place and held itself there, 3 were plated. All gave fair 
results. Fragments may be nailed on by approach from the joint 
surface and held in position, proA'ided the nail or screw is set into the 
cartilaginous surface, so that it does not irritate the joint surface 
opposite. Less of this has been done in the knee than in the head of 
the humerus. Sherman and Taif- report some interesting experimental 
work in this field on dogs, work in which they secured perfect aseptic 
healing without any interference with 
function, using the transarticular route. 
They have not used the method on human 
beings. Handley^ reported a case of 
transarticular fixation. of an elbow frac- 
ture in the humerus. 

Epiphyseal Separation. — The lower ep- 
iphysis is the first to appear, the centre 
showing at the ninth fetal month, and is 
the last to unite, some time from the 
twentieth to the twenty-fourth year. It 
may be separated at any time from birth 
up to twenty-one years, six and a half 
times more frequently in males than in 
females, and according to Poland, usually 
between the ages of thirteen to eighteen 
years, while Helgemeiner^ believes between 
the eighth and eighteenth year. Bruns 
says it is the most frequent of all epiphys- 
eal separations, citing it in 28 out of 100 
cases. Poland collected 114 cases and 
Helgemeiner, including Poland's, found 
194 cases and added 6 of his own up to 
1909. RusselP added 8 cases and Binney 
and Lund^ collected 18 cases occurring in 
the last thirteen years at the Boston City 
Hospital (P'ig. 464). Roentgenographic 
examination of the last ten years has dis- 
covered many of these cases as well as other instances of fractures 
difficult to recognize clinically and they are now thought of in differential 
diagnosis as much as fracture of the shaft. 

Cause. — 1. Predisposing; .syphilis, tuberculosis, rickets, and their 
effect on the epiphysis. 

2. Direct blow^ on the knee or lower thigh accounts for a few 
cases, as a horse kick or a sudden squeeze with a fall in the opposite 
direction. Such blows on the shaft above the epiphysis in a young 




Fig. 464. — Epiphyseal sepa- 
ration of the lower end of the 
femur with some comminution. 



■ Loc. cit. 

3 British Med. .Jour., 1912, ii, 860. 

* Ann. of Surg., Ivi, 809. 



2 SufK., Gyneo. and Obst., 

* Beitr. z. klin. C^hir., Ivii. 

* Boston City Hosp. Rep., 



No. 2, p. 1.31, 



1913. 16th Series 



002 FRACTURES OF THE FEMUR 

child lead to epiphyseal separation, as leg and knee, by means of the 
gastrocnemius and popliteus, are attached to the lower femoral epiphy- 
sis; the same force in adults leads to dislocation of the knee. 

3. Cases are caused by indirect violence and the leverage of over- 
extension of the leg. The thigh or leg, one or other, is fixed, and on 
application of force, the epiphyseal area gives. Most cases are due to 
the limb being caught in the spokes of a wheel. ^ 

Pathology. — The separation may be incomplete or complete, the 
former term covering the mere starting of the lower fragment out of 
its position as so frequently seen in epiphyseal injuries of the radius 
at the wrist. Most of the cartilage usually goes with the distal frag- 
ment, only a few shreds remaining on the shaft end. The incomplete 
variety may have displacement laterally or anteriorly, or a slight 
rotation. The periosteum is torn but not to any great degree. 
Hemorrhage into the tissues, secondary hemarthrosis, or effusion into 
the knee-joint commonly accompany the injury. Complete separa- 
tions allow displacement in any direction, but the frequent one is 
that of the lower fragment forward and upward, the shaft fragment 
downward and backward. The complete type may be complicated by 
fracture into the joint through the intercondyloid notch, or fracture 
of the diaphysis above. The second most common displacement is 
the diaphysis forward and the epiphysis backward into the popliteal 
space. On account of the violence causing these fractures many may 
be open. Binney and Lund found 5 open out of 18, with much lacera- 
tion of the soft parts. Associated conditions are injuries to the vessels 
and nerves and periosteal stripping for a distance up the shaft. For- 
merly these injuries were considered so severe that 63 out of 208 
cases were amputated at once, wdth high resultant mortality, but 
lately better treatment and Roentgen examination give much better 
results. When the periosteum is stripped up, hemorrhage or callus 
formation beneath it may cause late pressure on the vessels and 
nerves, or in cases of extreme displacement the lower end of the 
diaphysis may primarily burst through the popliteal skin, or later 
force its way out by pressure necrosis. A case reported by Russell 
was in a five-year-old boy who was caught in the spokes of a wagon. 
The leg was found semiflexed, rotated and displaced outward on the 
thigh, so that it looked like an outward dislocation of the knee-joint. 
Reduction under anesthesia was attempted but failed, and open opera- 
tion was done, whereupon it was found that the diaphysis had pene- 
trated into the vastus internus muscle. The periosteum was stripped 
off the shaft for several inches and had been buttonholed by the 
shaft, as its lower portion remained attached to the epiphysis. The 
displacement was corrected and the child allowed to walk eight weeks 
after the injury. 

Involvement of the external popliteal nerve is the common nerve 
complication resulting in toe-drop. If the nerve is not severed and 

1 Helgeraeiner, 171, Russell 4 out of 8, Binney and Lund 7 out of IS. 



FRACTURES OF THE UPPER EXD OF THE FEMUR 663 

early reduction is accomplished, this clears up in a few weeks. If 
the epiphysis is displaced forward, it is drawn upward by the quadriceps 
extensor. The popliteus and gastrocnemius muscles are attached 
posteriorly for the most part into the epiphyseal area, although some 
fibers of the latter are attached to the diaphysis. If the separation 
is not great these muscles are put on the stretch only, and when 
replacement is made they tend to hold position, but if the displace- 
ment has been extreme and these muscles have been torn from their 
insertion, they do not act as opponents to the quardiceps and do not 
help hold the reduction, so that recurrence of the forward dislocation 
is easier. However, the character of the plane of break is such that 
its roughness tends to cause firm fixation in many cases, if good 
reduction is performed. The periosteal stripping or the interposition 
of capsule or fascia may prevent reduction, especially when the leg 
is drawn out into extension. Treatment consists in flexion of the leg 
followed by traction and manipulation in that position, which may result 
in successful reduction on account of relaxation of the periosteal band. 

Symptoms and Diagnosis. — ^Separation of the lower epiphysis should 
be borne in mind in all injuries about the knee in patients up to twenty- 
four years of age. The findings are usually prominence in the patellar 
region with depression in the thigh just above, bony prominence in 
the popliteal region from the displaced upper fragment, false point 
of motion just above the knee-joint, absence of crepitus or very soft 
crepitus, and shortening. With little swelling or displacement no 
interference with the blood supply of the leg is expected. If these 
are great, the leg may be cold and edematous, and no pulsation can 
be felt in the dorsalis pedis artery. Differentiation from supracondy- 
loid fracture or dislocation of the knee is important. In children 
supracondyloid fracture is rare, is higher, and the lower fragment is 
usually displaced backward. Fig. 446 is given as an illustration of 
supracondyloid fracture just above the closed epiphyseal line. In 
dislocation the condyles of the femur lose their relation to the head 
of the tibia and the knee movements are greatly restricted, while 
this is not so in epiphyseal separation. If the epiphysis is displaced 
posteriorly, as in rare cases, the differentiation from dislocation back- 
ward of the knee is very difficult, and the roentgenogram is necessary. 

This separation possesses a greater tendency to recurrence than 
any other in the body involving the long bones, with the possible 
exception of the upper end of the humerus. After reduction and 
fixation, either checking examination for observation of the deformity 
or condition of the circulation or roentgenograms should be made. 
As a rule, good functional results follow reduction, and arrest of growth 
in the bone is not common. There is danger of it, however, and the 
prognosis should always take that into consideration. Broca^ found 
one case of shortening of nearly two inches four years after operative 
reduction, and KebouP reported a case of lateral deformity when the 

' C'ongres de C'hir., 1004, xvii, 020. 2 Ibid, p. 017. 



664 FRACTURES OF THE FEMUR 

arrested growth affected one side more than the other, so that genu 
valgum was present. Screws, phites, nails, or any foreign bodies which 
pass through epiphyses may cause interference with growth. Other 
references to cases are made by Bertram,^ who reports 3 cases, all of 
the epiphyses being dislocated forward; 2 reduced without and 1 with 
open operation. Drew^ reports a case in a boy, aged eight and a half 
years, on whom open operation was done and a Lane plate applied. 
Fillet^ records a case in a child, aged six years, who had trophic changes 
in the lower extremity from pressure on the nerves. The diaphysis 
was resected after three months with good functional result. 

Treatment. — Because of injury to the cartilage of the epiphysis, 
early and complete restoration to normal position should be attempted. 
If there is much cramping of muscles or rigidity, anesthesia should 
be used at the attempt. In cases of simple complete separation with 
little displacement, correction by extension and manipulation followed 
by fixation in a slightly flexed position by a plaster splint is sufficient. 
If the displacement ,has been greater, simple extension often fails to 
effect reduction, but if the leg is flexed to a right angle and traction 
then made in the longitudinal axis of the thigh aided by pressure on 
its lower fragment in front, most cases can be reduced. Unfortunately 
these cases tend to recur so that it is often impossible to put them 
into extension and a permanent dressing, consequently a plaster 
cast or swathe in a position of flexion at a right angle is the best 
treatment, but this should be followed by checking roentgenograms 
for determining whether the reduction holds. Also assurance must be 
had that there exists no pressure on the popliteal vessels and nerves. 
In difficult reductions where open operation is not permitted, the 
heads of the gastrocnemius may be cut, or a tenotomy of the tendo- 
Achilles may allow sufficient relaxation for reposition. 
• If attempt fails through manipulation under anesthesia, or in open 
cases, operation should be done at once. Painstaking careful adjust- 
ment of fragments by leverage and traction without resection of the 
diaphysis or any part of the epiphysis should be done, perseverance 
being the best tool to use. If displacement tends to recur, a nail or 
screw can be driven diagonally through the diaphysis to hold the 
lower fragment, or if the lower fragment is split, it may be nailed onto 
the diaphysis by a nail or screw from either the shaft or joint side; 
if the latter, care must be taken to counter-sink the heads, as foreign 
bodies sometimes interfere with the growing function. They should 
be removed after union has taken place, generally in three weeks. 
For that reason alone, except in rare cases, fixation from the joint 
side will not often be done. A plaster splint with the leg in very 
slight flexion is the best permanent dressing, although some prefer 
a ham splint. After three weeks, passive m^otion should be started, 
provided it is painless and the joint is not distended. Under the same 

1 Miinchen. med. Wchnschr., March 21, 1911, No. 12. 

2 Roy. Soc. Med., London, Orthop. Section, January 20, 1910. 

3 Soc. de Chir. de Paris, 1911, xxxvii. No. 1. 



FRACTURES OF THE UPPER END OF THE FEMUR 



665 



restriction active use can be started in six to eight weeks. Later, 
secondary treatment may be necessary for vascular changes or incki- 
sion of nerve in the calkis causing toe-drop or trophic changes. If 
cases are diagnosed early and reduced, or if old joint motion still 
remains, excision of the knee-joint should never be done, but open 
operation, tenotomies, and freeing of the fragments, with some freshen- 
ing of the surfaces, will give reduction. In every case this important 
epiphysis should be conserved for its future growth. 

Fracture of the Condyles and Epicondyles. — Separation of either 
condyle is usually caused by direct violence, as a squeeze between 
heavy objects, or a twisting of the leg with the thigh fixed. The 





Fig. 465. — Fracture of the external con- 
dyle of the femur caused by direct violence 
with backward di-splacement. The knee 
appears dislocated backward. 



Fig. 466. — Reduction of this frac- 
ture by mechanical extension and direct 
pressure. 



tearing-out force of the bone at the insertion of the knee ligaments 
also causes lesser fractures. The breaking off of larger fragments is 
due to direct violence and may be accompanied by much laceration 
of the skin and soft parts, so that a large percentage of these injuries 
are open (Figs. 465, 466, 467, 468, and 469). By indirect violence, 
following a driving upward force of the head of the tibia, a portion 
of the condyle may be split off or the plane of fracture will be found 
starting at the intercondyloid notch running obliquely and laterally 
upward and outward. The split in the lower end of the femur in some 
of these injuries may extend for several inches up the shaft, and there 
is a little displacement laterally. When the bulk of the condyle is 
cracked off' by direct violence, its displacement may be quite marked 



006 



FRACTURES OF THE FEMUR 



and is usually backward and upward, or it may be lateral and upward. 
The lateral ligamentous structures retain their hold above and pre- 
vent serious displacement unless they are ruptured. The crucial 
lioaments may be simultaneously injured. In lateral displacement 
the knee appears wider. 

Joint injury with effusion or blood always is present and may be 
so marked that the fracture is not suspected until the swelling of the 
knee has subsided. In lacerations and open wounds the broken portion 
may be visible and can be replaced in the first dressing. If reduc- 
tion cannot be maintained, a nail should be driven through the frag- 




FiG. 467. — Fracture of the internal condyle with complete revolution of the fragment. 



ment to hold it in place. Many instances of severe sprain or trauma 
to the knee which cause these fractures are so quickly followed by 
swelling and effusion into the knee-joint that the acute symptoms and, 
signs mask the real condition. After rest, aspiration of the joint, or 
strapping and application of ice, if the function does not improve, 
very careful examination should be made in attempt to discover any 
loose bone fragment, crepitus, or a semidislocation of the leg backward 
or forward. Where the lateral support is weakened on one side of the 
joint by fracture of the condyle, the leg bones tend to be displaced 
posteriorly on that side. Rarely the fragment is' pushed forward, 



FRACTURES OF THE UPPER END OF THE FEMUR 067 

but the patellar tendon and the strong lateral ligament restrict dis- 
placement in that direction, and as the knee assumes a position of 
partial flexion, the relaxation of the gastrocnemius and lateral liga- 
ment on the posterior aspect favor a posterior displacement more 
often. 

Diagnosis. — The diagnosis is not easy. Careful palpation to test 
the bony contour in all its aspects, search for a loose fragment or 
crepitus, or a constant point of tenderness on pressure are needed 
(Figs. 470 and 471). Added to this is the loss of function and delayed 





Fig. 468. — Anteroposterior viev*' of in- 
ternal condyle fracture with revolution of 
the fragment. 



Fig. 469. — Repair of the condylar 
fracture. Open operation. No foreign 
material. 



recovery, and the finding of a slight displacement of the knee to one 
side or other. Very small fragments or sprain fractures arising from 
tearing out of ligamentous insertion are decided by the roentgenogram 
after the finding of a persisting small area of tenderness to pressure 
with ecchymosis. Some of these small fragments are painful, either 
because of nerve pressure or a low-grade inflammation with attempts 
at bone development. Others never attempt to unite, as no immob- 
ilization has ever been allowed, and they may become sesamoid in 
character by the constant rubbing of use, their surfaces becoming 



068 



FRACTURES OF THE FEMUR 



smooth until no pain from friction follows. These may sometimes 
be palpated. It is important to differentiate from enlarged or trau- 
matized sesamoids which are frequently found in the head of the 
gastrocnemii muscles. Several cases reported in the literature with 
illustrations, 1 am sure, are nothing more nor less than insulted sesa- 
moids. Some fragments of appreciable size never unite, become freely 
movable, and may cause so much pain or disability that their 
removal is necessarv. 





Fig. 470. — Fracture of the external 
condyle by direct violence. 



Fig. 471. — Comminuted fracture of 
the internal condyle involving the knee- 
joint. 



Treatment. — Treatment of small sprain fracture fragments consists 
in the strapping of the contused area, or in immobilization of the 
knee in a moulded splint from thigh to ankle for ten days. If a loose, 
fragment can be palpated and it causes pain or disability, a shorter 
convalescence can be promised if it is attached with a small nail. 
Skillern^ records a case of sprain fracture of the adductor tubercle of 
the femur caused by a blow on the lower part of the thigh. The skia- 
gram shows clearly separation of the tubercle and a shadow of the 



Ann. of Surg., Ixvii, 290. 



FRACTURES OF THE UPPER EXD OF THE FEMUR GG9 

adductor magnus muscle leading to it. Ishimoto and Kaneko^ have 
reported 6 cases of fracture of the internal epicondyle, 1 of which was 
operated on. They reviewed Vogel's 5 cases and believe that they are 
caused by contraction of the gastrocnemii. The fragments are found 
to be rough on the inner surface and correspond in other ways to the 
fragments of sprain fracture. Old cases are sometimes mistaken for 
myositis ossificans, from which they are hard to differentiate. If there 
is a complete hiatus between the shadow of the fragment and the 
femur, we may well suppose that the injury was a fracture. If the 
shadows merge and extend out into the muscle insertion, it is difficult 
to say whether a fragment has been fractured off and united again or 
whether the tearing has caused not fracture, but a deposition of lime 
salts in the muscle insertion (see chapter on Bone). It is more simple 
to believe that some lesion, though small, of the bony continuity 
has occurred, allowing the freedom of osteoblasts and a resulting bony 
gro\si:h. 

Fractures of the condyles with displacement should be reduced, as 
they tend to interfere seriously with joint function. Many can be 
reduced by means of mechanical extension in a straight line with 
manipulation for pushing the fragment into position. Illustration 
is given of such a case which was not diagnosed until it was observed 
that a suspected knee dislocation, which w^as supposed to be reduced, 
seemed to have recurred. Roentgenogram revealed the broken con- 
dyle, but as the soft parts were contused and the skin was in no con- 
dition for open operation, reduction was attempted by manipulation. 
With three assistants making traction during anesthesia, nothing could 
be accomplished; but by mechanical extension, the gastrocnemius 
fibers pulling on the fragment, I was able to make complete reduction 
by pushing the fragment down into place, feeling it slip into position 
with a distinct grinding snap. The leg was put in a plaster splint 
in extension; no tendency to recur manifested itself, and after six 
weeks the man had 95 per cent, function in the knee. 

Spalding^ reports a case of separation of the internal condyle of 
the femur in a man aged forty-seven years. Open operation lasting 
over an hour was performed; four small bone fragments were removed, 
and although he nailed the fragment on after pushing it down into 
position, he failed to get an anatomical reposition. The man had 
flexion to a right angle and almost complete extension. There was no 
reproduction of the roentgenogram. Cases which cannot be reduced 
by mechanical extension and manipulation or which are comminuted 
should be fixed by nail or screw through a small incision over the 
condyle concerned. If the mechanical extension is thoroughly tried 
out first, few cases will demand operation. Postreductive roentgeno- 
gram for checking should be made at once. 

* Am. Jour.Orthop. Surg., ix, 241. 

2 Kentucky Med. .Jour., xii, No. 12, p. 380. 



CHAPTER XXIII. 
DISLOCATIONS OF THE HIP. 

Preliminary to the discussion of fracture of the femur the structure 
of the hip-joint was outHned, and in connection with the central dis- 
location of the femur the formation of the acetabulum by the fusion 
of the three pelvic bones was described. When the body lies on a 
flat surface the pubes are the highest point in front, the hip socket 
lying midway between the level of the pubes and the floor, looking 
upward and outward (Fig. 472). In an erect position of the body the 
sockets look downward and outward, and the other surfaces of the 
pelvic bones recede from the hip socket to leave it standing out in 
bold relief, the femur being allowed a corresponding freedom of range 
of motion at the hip. The acetabulum is deepened and sharpened 
by a cartilaginous rim and the cotyloid ligament across the cotyloid 




Fig. 472. — Position of the hip sockets, body lying on a flat surface. The pubes highest 
point in front. Head of femur dislocated forward. Adapted from AUis. 

notch, and the femoral head is partly held by the ligamentum teres 
inserted in the lower part of its spherical surface. AUis believes that 
the round ligament has little relative power on the head of the joint, 
because it is not strong enough to prevent dislocation. It is absent in 
the orang-outang and elephant, but acts rather as an accessory lubricat- 
ing agent of the joint. At the centre and the inferior margin the 
acetabular wall is thin; posteriorly and around the peripheral margin 
it is heavy. The anterior ligament, as we have seen, is the most impor- 
tant one, and its strong fibers passing from the antero-inferior iliac 
spine to an insertion along the intertrochanteric line on the femur 
are called the iliotrochanteric or Y-ligament. Bigelow states that 
this is the strongest ligament in the whole body and that its function 
is one of checking extreme motions of the hip, the inner band restrict- 
ing the extension of the femur and the outer band, outward rotation 
fFig. 473). Acting in an accessory capacity to the Y-ligament are the 
ischiofemoral and pubofemoral ligaments, the former supporting the 



DISLOCATIOXS OF THE HIP 671 

posterior part of the capsule from the ischium to the femur, aud the 
latter extending from the pubic bone in front of the acetabular margin 
to the femur above the lesser trochanter. 

The head of the femur lies buried less than one-half in the hip 
socket, being held by atmospheric pressure and the ligaments described. 
The retentive apparatus of the head holds it securely in the socket 
without the aid of the capside, which, if it served this purpose, would 
always be tense. The capsule really is meant to restrict exaggerated 
movements, and Allis believes that the head is held in the socket by 
the cotyloid rim or sucker ligament, basing his conclusion on his own 
and Weber's experiments. They found that after the entire capsule 
was cut awav it ^vas difHcult to draw the head from the socket. 




Fig. 473. — The iliofemoral, or Y-ligament. (Bigelow.) 

For description of Bryant's triangle and the Roser-Xelaton line 
which crosses just above the upper margin of the greater trochanter 
of the femur, together with methods of measuring the leg, the reader 
is referred to the chapter on Fracture of the Femur. Hip motions 
of extension anrl abduction are checked by the ligaments, the iliopsoas 
muscle, and the other muscles about the joint, and flexion and adduc- 
tion of the thigh are limited by contact with the soft ])arts and the 
restraint of muscles crossing the outer aspect of the hip-joint. 

Hip disl(K'ation is relatively uncommon, especially when com- 
I)ared with fracture of the femoral neck diagnosed by the roentgeno- 



072 DISLOCATIONS OF THE HIP 

gram. In my collection of 796 dislocations at the Cook County 
Hospital I find 39 dislocations of the hip, or approximately 5 per cent., 
occurred in the period during which there were over a thousand frac- 
tures of the femur admitted to the hospital. The statistics of other col- 
lections have varied from 1.5 per cent, to 9.75 per cent.^ Thirteen of 
the 39 traumatic hip dislocations mentioned were in children under 
fifteen years of age, a much higher proportion than recorded by most 
authors. Boehnke^ made a study of hip luxation in children and 
believed that they were rare. He collected but 29 cases from the 
literature and added 1 from the Halle clinic in a five-year-old boy. 
In Malgaigne's statistics there was 1 case in the first decade and 3 
in the second decade of life. Weber gave 3 in the first and 2 in the 
second; Prahl, 12 in the first and 8 in the second decade out of a 
total of 41 cases.^ The youngest case was probably under one year 
of age. Stimson says the youngest patient was six months;^ and 
Boehnke says eleven months in his enumeration of 29 cases. The 
more recent reports include cases in children of seven years by Carlill,^ 
nine years by Rischbieth,^ eight years by Keenan,^ and Boehnke's 
case mentioned previously. Steinke's collection of 10 cases of recent 
traumatic hip dislocation contained one of a boy a^ed ten years. Hamil- 
ton gives the greatest frequency of traumatic hip luxation as occurring 
between the ages of fifteen and thirty years. Naturally young adult 
males are more disposed to the severe traumata which cause hip dis- 
location. Corner^ analyzed the statistics on this subject at St. Thomas's 
Hospital since 1890. He found the luxation in 27 males compared to 
5 females. There were more cases in the tenth to twentieth year 
period, which he calls the heedless decade in those who cross roads. 
The second greatest period of frequency lay in the decade from forty to 
fifty among those road-crossers who are less active, but who will not 
confess it. These facts are interesting, as they concern the number 
of accidents in modern large cities caused by persons being knocked 
down by motor vehicles and vans. 

Simultaneous traumatic dislocations of both hips have been 
recorded in 41 cases. These are caused from heavy blows on the 
lumbar region, falls from a height onto the feet, or crushes from 
heavy falling bodies. The dislocations may be dissimilar, one side 
going backward, the other forward, because the patient is twisted or 
bent over by the trauma. Sladden^ reported a case in a twenty-four- 
\^ear-old man who was knocked over by an automobile while riding 
his bicycle. Both legs were flexed at the hip, and he could not walk. 
On the right side he had a posterior luxation with two and a half 
inches' shortening of the leg; on the left side the femoral head lay 
near the sciatic notch and was one and a half inches short. Both 

1 Agnew, Surg., ii, 89. 2 Arch. f. klin. Chir., 1913, Bd. cii, 1077. 

3 Inaug. Dis., Centralbl. f. Chir., 1881, p. 57. 

* Gross's case, reported by Johnson, Philadelphia Med. Times, 1876-7, vii, 5. 

5 Lancet, London, 1914, i, 1288. ^ ibid., p. 1111. 

' Ibid., p. 1359. 8 Practitioner, London, 1914, xciii, 184, 

9 Lancet, London, 1912, ii, 1013. 



DISLOCATIONS OF THE HIP 



673 



sides were reduced, and in three months there was freedom from all 
disturbance in the hips. Chace^ reported a case and revicAved the 
Hterature of 39 previous cases, 5 of which were poorly reported, the 
ages A'arying from eight to sixty-five years. There are 7 cases of 
double iliac dislocation, but Chace's case is the first double ischiatic 
reported. The prognosis as to life and function is good. Of 35 cases 
both sides have been successfully reduced in 26; 3 deaths are recorded. 
Open dislocations of the hip are rare. They are caused by severe 
crushing injuries, or falls from a height. The head of the bone may 
be forced out in any direction through the soft parts, and the con- 
comitant injuries make the prognosis poor. The mortality in the 
reported cases has been over 60 per cent., partly from the primary 





Fig. 474. — Division of hip 
dislocations by line from the 
anterior inferior iliac spine 
through the centre of the acetab- 
ulum. Dislocations in front of 
this line are anterior, back of 
the line, posterior. 



Fig. 475. — -AUis's line for division of hip dislo- 
cation into outward and inward luxations. 



injury and shock, and partly from operative procedure or sepsis. The 
large bloodvessels are rarely injured. The treatment is first directed 
toward the shock. When that is combated, reduction with or with- 
out the resection of the head is necessary. General anesthesia is 
used, and the hip-joint is thoroughly drained by through-and-through 
strips of folded gutta-percha. Whenever possible, the whole bone 
should be preserved, head excision being reserved for irreducible 
cases or those which are septic. 

Classification and Mechanism. — For most students and practitioners 
hip dislocations have been a mysterious mass of overclassified injuries. 
The matter of descriptive nomenclature should be simplified so that 
general types may be easily recognized, and the diagnosis of positions 



' New York Med. Jour., 1912, xcv, 171 



074 DISLOCATIONS OF THE HIP 

of socoiulary displacement with slight difference should be discarded, 
so that for practical purposes treatment can be supplied on the basis 
of a broader understanding. Bigelow's work descriptive of the Y- 
ligament and its function at the hip-joint offers an opportunity for 
one to clarify these luxations, and the best classification is one which 
considers the position of the luxated bone in reference to its relation 
to the plane of the important ligament. Manipulation and gravity 
may cause varying secondary displacements, but they are of little 
practical importance in treatment, and one cannot help agreeing 
with Cotton, Corner, and others' that a division into posterior and 
anterior luxation is ample (Fig. 474). The plane of division may be 
made the plane of the Y-ligament, or a line may be drawn from the 
antero-inferior iliac spine through the centre of the acetabular cavity. 
\Yhen the head is displaced in front of this plane, the luxation is called 
an anterior luxation; when it is posterior to this plane, it is a posterior i 
luxation (Fig. 475). A few dislocations, the result of extreme violence, " 
which ruptures all ligaments, may move the head in any direction 
because all restriction of displacement is lost. Central dislocation 
of the femoral head has been considered under the heading of Pelvic 
Fracture, which see. , 



HIP DISLOCATIONS. 

1. Posterior — including the dorsal, everted dorsal, and so-called 
ischiatic types. 

2. Anterior — Including the pubic, perineal, and obturator types. 
General Mechanism of Hip Dislocations. — Autopsy findings and 

experimental work prove conclusively that in nearly all hip disloca- 
tions the capsular tear which permits escape of the head of the bone 
is below the line drawn from the antero-inferior iliac spine through 
the centre of the acetabulum. This tear has been caused by leverage 
action, the lever being one of the first class, and the difference between 
anterior and posterior dislocation is largely in the anatomical part 
used as a fulcrum. When the leg is adducted and rotated inward 
and is subjected to violence, which transmits itself along the axis of 
the leg, the leg represents the long arm of the lever with the power, 
the tense iliofemoral ligament is the fulcrum, and the capsular and 
ligamentum teres resistance at the end of the short arm or head of 
the bone represents the weight. The capsule gives in its inferior 
and backward portion, and when the head slips out, displacement 
becomes posterior to the plane of the Y-ligament. It may assume 
different positioiis, aided by further adduction, which carries the 
head down and backward, or a backward thrust, which carries it back- 
ward and upward. Hyperabduction of the femur, on the other hand, 
causes the greater trochanter to strike against the surface of the 
ilium as the neck impinges against the acetabular rim and a bony 
fulcrum is formed. The capsule again tears in its lower portion, lower 
than in an adduction mechanism, but as the thigh is abducted and 



HIP DISLOCATIONS 675 

possibly rotated outward, the femoral head is turned forward, and 
after its escape tends to lie forward of the iliofemoral ligament. 

The Y-ligament is not torn in most cases of luxation, and its restraint 
controls the secondar}^ displacement of the head of the bone. As 
long as this ligament is intact the dislocation remains within a typical 
classification, and the position of the limb is characteristic. An intact 
condition of the ligament also is of great importance in treatment, 
so that the following simple characteristic positions with an unruptured 
Y-ligament should be understood. 

1. Position of the leg. 

In anterior dislocation the leg is flexed, abducted, and everted. 
In posterior dislocation the leg is flexed, adducted, and inverted. 

2. Position of the greater trochanter. 

In anterior dislocation it is displaced backward. 
In posterior dislocation it is displaced forw^ard. 

3. Position of the head of the femur. 

In anterior dislocation it is near the pubis and easily felt. 

In posterior dislocation it is in the buttock and difficult to feel. 

Direct power which tries to shorten the distance between the 
adducted knee and the trunk may produce luxation by a direct thrust 
of the femoral head out backward in spite of ah muscular and ligamen- 
tous restraint. This is a'rare cause of luxation, the excursion of the 
head^being'Jimited by the surrounding tissues. Frequently on account 
of jnanipulation or continued force an anterior dislocation may become 
a posterior one, or vice versa, verifying the fact of the capsular tear 
below the centre of the acetabulum, its extent varying to let the 
head escape either forward or backward. Powerful force may drive 
the upper end of the femur in any direction, even through the acetab- 
ular wall into the pelvis-^central dislocation. The positions assumed 
are always grotesque and vary widely from the general characteristic 
positions suggested. 

Posterior Dislocations. — The posterior hip luxations are the most 
frequent, occurring about seven times as often as anterior dislocations. 
The femoral head is sprung out of the acetabulum, while the leg is 
in the usual position of adduction, flexion and inward rotation, and 
after mounting over the posterior acetabular rim, comes to rest at any 
point above or behind the acetabulum on the dorsum ilii or more 
toward the ischiatic notch. The weight of the leg or subsequent 
movements and manipulation may shove the head from a position near 
the acetabular rim to one farther backward and upward. 

Causes. — The usual mechanism of posterior dislocation is found 
when the leg is in flexion, adduction and inward rotation, and force 
is applied to the hip-joint from above by heavy weights falling on 
the body, or from below on the knee or foot when the pelvis is fixed 
as the patient lies on the ground. The patient might also be caught 
between large objects when he is upright and supj)orting a suddenly 
ap])Hed heavy weight with the leg in an abducted and extended posi- 
tion. 'Jhe luxated hip has probably borne the greater part of the 



()7() DISLOCATIONS OF THE HIP 

burden. Exaggerated adduction is often a cause, the thigh being 
pressed across the opposite thigh by a force. Squeezes between cars 
and engines, or between boats and docks, with the leg drawn up into 
this i)osition, have caused luxation. On the cadaver this method usually 
produces a prompt luxation. Spontaneous or static dorsal dislocation 
of the hip may occur in patients of any age in the course of a prolonged 
rest in bed. Ligaments and muscles become atrophic and relaxed, 
so that sudden turns of the patient by the nurse or a twisting of the 
leg may produce dislocation. Ridlon^ states his belief that many 
so-called cases of congenital hip dislocation are really spontaneous 
dislocations, and no one can tell just when the femur went out of 
joint. Many of them do not occur until after the child has started to 
walk. Ashley^ reported a case of static dislocation in a seven-year-old 
girl who had suffered extensive burns and lay prone with her weight 
on the left elbow and knee for eight months. Shortening of the 
muscles and the position had caused the femur head to move below 
the acetabulum onto the lower edge of the pubis. There were no 
cicatricial contractions about the hip. Reduction was made by 
manipulation. 

Ombredanne^ reported a case of voluntary dislocation of the hip in 
a thirteen-year-old girl who, after a year's experience in throwing the 
hip out of the socket to amuse herself, was able to repeat the act at 
will. To cause the dislocation she advanced the knee, rested the 
toes on the ground, and then suddenly stood erect. The surgeon's 
hand placed on her hip could feel the head go up back of the joint 
and then suddenly slip back into the cotyloid cavity. In this case 
it was believed that there was a congenital aplasia of the posterior 
part of the acetabulum and capsule which had been further weakened 
by the acquired stretching of the muscles. Heully^ has seen a similar 
case, and Bigelow^ mentioned seeing 3 cases, one in an adult soldier. 
Hamilton also collected 3 cases. 

Spontaneous dislocation after typhoid fever does not belong in the 
traumatic class. The luxation is associated with effusion into the 
joint and should be classed with the luxations following the arthritides 
of acute infectious diseases like scarlatina, influenza, etc. An acute 
process has weakened or destroyed the capsule and ligaments. A 
class of luxations is found following paralyses which involve groups 
of muscles about the hip. Active muscles overcome the normal joint 
resistance by pulling eccentrically to the acetabulum and cause luxa- 
tion of the head forward when the abductors are intact, and upward 
and backward when the adductors are active. 

*^' Pathology. —The capsular tear is usually in the lower portion pos- 
teriorly, and the size of the opening varies. In the regular forms it 

1 Am. Jour. Orihop. Surg., 1914, xii, 673. 

2 New York Med. Jour., 1915, ci, 608. 

3 Rev. d'Orthop., 1912, 3 S., iii, 396. 

■i Rev. de Chir., June, 1911, obs. xxvi, 771. 
6 The Hip, p. 112. 



HIP DISLOCATIONS 677 

is at least large enough to let the head escape, and the Y-ligament is 
not injured. In the irregular forms all the ligaments, induding the 
iliofemoral, are torn away. This condition has been proved by 
autopsies on patients dying within a few days after hip luxation, or 
by first-hand inspection by arthrotomy on fresh dislocations. The 
ligamentum teres may be ruptured in its continuity or more frequently 
is torn away at the femoral head. As the head of the femur is luxated 
out of the socket, it usually comes below the obturator internus muscle, 
and in the subsequent displacement backward this muscle is pulled 
behind, so that it lies between the femoral neck and the acetabulum. 
The pyriformis, obturator externus, gemelli, and quadratus femoris 
muscles are frequently torn, but any group of them may be spared 
with increased laceration of their neighbors. They lie in close contact 
with the capsule and may be torn by the original trauma of luxation 
or by the subsequent pressure of the neck and head of the bone passing 
to its ultimate displacement. The glutei are not often lacerated, but 
the quadratus femoris was found by Bollinger torn in 11 out of 12 
cases. 

The acetabular edge or the pelvis may be fractured. In 7 cases 
Dollinger found 2 fractures of the acetabulum and 2 of the pelvis. 
The head of the femur may also be fractured. Crile^ reported a case 
involving the posterior portion of the head and acetabular rim. 

Position of the Femoral Head. — Like all ball-and-socket joints, the 
head of the displaced bone may lie near the socket rim in the hip, or 
at as great a distance as surrounding structures will permit. The 
usual position is that which has been described as "low dorsal" when 
head is between the ischiatic notch and the acetabulum (Fig. 476). 
When it moves higher up posteriorly and comes to lie on the dorsum 
ilii it is called ''high dorsal." In the low form the head has been 
found at the base of the ischial spine. "Everted dorsal" is a rare 
secondary position, described by Bigelow, in which the thigh is pressed 
back, abducted and rotated outward after the head has escaped from 
the capsule. This position puts so much stress on the outer fibers of 
the iliofemoral ligament that they rupture, and the intact remaining 
portion pulls the femoral head forward over the ilium toward the 
anterior inferior spine. This type has also been termed the "supra- 
cotyloid." 

In the high dorsal dislocations, which are seldom seen, the head 
lies more backward and upward than it does distinctly upward. jNIal- 
gaigne found in 5 cases out of 11 examined that the head had risen 
only to the level of a line from the antero-inferior iliac spine to the 
upper margin of the great sciatic notch and in the others not more 
than an inch above the line in any case. 

Dollinger^ reported on 22 cases of hip dislocation, 4 of which were 
reduced by manipulation after four, six, eight, and nine weeks respec- 
tively. Although he made attempts to reduce the others by bloodless 

1 Ann. of Surg., May, 1801. 2 Ergebnisse der Chir., iii. 



678 



DISLOCATIONS OF THE HIP 



methods he had no other successes, and subsequent arthrotomy 
demonstrated the reasons. After violent manipulative efforts the 
femoral heads showed abrasions and contusions. The permanent 
changes about the luxation were divided into four groups: 

1. There were changes in the acetabulum. Every case but one was 
filled with connective tissue proliferated from the capsular shreds 
and fat, all grown into a mass, which had to be cut out piece by piece 
to expose the acetabulum. Beneath, the cartilage was intact except 
in two long-standing cases. 




Fig. 476. 



-Usual posterior hip dislocation. Head back of the acetabulum, trochanter 
elevated. 



2. Changes in the femoral head were few except in one case of 
long standing — nine months — in which there was a gnawed appearance 
of the bone. The head was uniformly surrounded by the proliferated 
periosteum in its new position, and the neck was adherent to the 
pelvis by thick connective tissue. 

3. Changes in the capsule were very marked. The capsule could 
not be identified nor dissected free from the cicatricial mass about the 
head, and no site of rupture could be identified. 

4. Changes in the muscles were those of shortening and disuse, 
although, as previously stated, the quadratus femoris W-as torn in 
every case but one. The shortening of the piriformis, obturator inter- 
nus, and gemelli were amenable to stretching by traction with a block 
and pulley. 



HIP DISLOCATIONS 



679 



Symptoms. — The patient is, as a rule, unable to rise to a standing- 
position. He lies on the ground, holding the dislocated leg rigidly 
in a position of flexion, adduction, and inward rotation, so that the 
foot rests on the dorsum of the opposite foot, or the knee lies resting 
on the front of the opposite knee a few inches above the joint (Fig. 



k 




Fig. 477. — Dorsal dislocation of the hip. (Stimson.) 



477). The position of the head in luxation without fracture has been 
considered to be the same as the position of the internal condyle of 
the femur inasmuch as they point in the same direction. The surgeon 
is assisted by this fact in determining the direction of the axis of the 
neck in dislocation, or he may use the axis of the foot as a guide, 



680 DISLOCATIONS OF THE HIP 

taking into consideration that it points at right angles to the condyle. 
Active movements are not possible. Passively the injured thigh can 
be flexed and probably slightly more adducted, but abduction and 
extension are not possible, and the attempts cause pain. In some 
cases the leg can be brought down flat into a line with the opposite 
leg by flexion of the spine, the position of lordosis being seen or felt 
by the hand slipped under the back at the pelvic rim. Examination 
of the hip region shows that the greater trochanter of the femur has 
risen above Nelaton's line, and the gluteal fold on the injured side is 
less pronounced and is higher than on the sound side. Palpation in 
very thin subjects may permit the surgeon to feel vaguely the head 
move beneath the gluteal mass, but where there is much subcutaneous 
fat, it is impossible to palpate the head accurately. In front of the 
joint the normal fulness caused by the presence of the head below 
Poupart's ligament is lacking, and a finger can be depressed deeply 
into the tissues. The difference from the normal side is striking, and 
the findings are also the opposite of fracture of the femoral neck, in 
which the depressibility of the tissues in front of the joint is dimin- 
ished. 

The degree of flexion and inversion of the leg varies with the dis- 
placement of the head away from the acetabular rim and with the 
tension of the Y-ligament fibers which anchor the intertrochanteric 
line to the anterior inferior iliac spine. When the head is in a position 
near the ischiatic notch and the ligament is intact, the leg must lie 
in marked inversion. Posterior dislocation on the ilium is not accom- 
panied by a great amount of inversion, because the tension of the 
ligament is somewhat relaxed, and in the everted dorsal luxation the 
ligament being ruptured, inversion no longer exists but gives way to 
eversion. 

Adduction and flexion also depend on the integrity of the iliofemoral 
ligament and the position of the head, A high posterior position of 
the head will let the leg extend downward until there is but slight 
flexion compared to the opposite side. Low positions of the head just 
back of the lower acetabular edge will bring the leg into greatest 
flexion and adduction. Muscular action may influence the positions 
of flexion and adduction somewhat, especially if the dislocated head 
is hooked under the external rotators, which remain intact and hold 
the head in position, a condition which can be maintained only by 
flexion and adduction of the leg. 

Shortening is more apparent than real, the true anatomical length 
being disguised by the soft parts covering the bone and the clinical 
obstacles to critical measurement. In the chapter on Fracture of the 
Femur the methods of measuring the leg are given, and attention is 
directed to the necessity of placing the limbs in a corresponding posi- 
tion of flexion on the trunk and at an equal angle with the long axis 
of the body drawn perpendicular to the transverse pelvic axis. The 
flexed position of hip luxation is rigidly fixed, and the leg cannot be 
brought into a position corresponding to the uninjured leg, which also 



HIP DISLOCATIONS 681 

cannot be carried into the flexed and adducted position on account of 
interference between the two legs. Length measurements are therefore 
unrehable and fortunately are not necessary for diagnosis. Apparent 
shortening may be two or three inches, whereas real shortening 
probably does not amount to more than an inch. The distance from 
the anterior superior iliac spine to the tip of the greater trochanter is 
lessened in posterior dislocations, usually not to exceed one inch. 

Everted dorsal dislocation dift'ers from the usual posterior luxation, 
because the leg is everted, instead of lying in inversion, as do all other 
posterior displacements. As we have seen, this position is caused by 
the rupture of the outer fibers of the ligament, and the head is drawn 
upward by the remaining intact portion above the acetabulum. 
Bigelow first described this type, the leg lying in e version and outward 
rotation, with shortening of two inches or more. The head of the 
femur may be drawn upward to lie between the two anterior iliac 
spines. Violent eftorts at reduction of posterior luxations may rupture 
the Y-ligament, and an everted dorsal luxation results. Lente^ recorded 
a case of this kind which followed traction and outward rotation. 
Van Buren Seines, Kocher, and Stimson have reported cases which 
were recognized as everted dorsal dislocations. The head does not 
lie on the broad iliac surface but is supracotyloid, and lies far forward, 
so that there is more or less e version instead of inversion of the limb. 
Extension is not interfered with; so there is no flexion of the thigh, 
and the leg lies in an extended position, its longitudinal axis but slightly 
disturbed. There is free mobility in the hip, and the leg is usually 
rotated outward, with shortening, which leads the surgeon to expect 
fracture of the femoral neck. 

AUis^ reported a case of a man who was leading a horse which fell 
on him after rearing on the ice. His thigh was abducted and slightly 
flexed at both hip and knee, the foot being turned outward. Reduc- 
tion was accomplished by the surgeon fastening the pelvis to the 
floor, flexing the leg on the thigh and the thigh on the pelvis, and 
following with traction upward until the femoral head reached the 
socket. Eftorts to reproduce the condition of everted dorsal dislocation 
were made on a cadaver strapped to the table. The femur was flexed 
to a right angle with the pelvis, the leg being at right angles to the 
thigh, the knee was steadied by the operator's hand, and the femur 
was rotated by his seizing the ankle and turning it inward toward the 
pubis like a wheel spoke. This rotation ruptured the capsule, and the 
head fell out of the socket into eversion, but fracture of the femur 
was produced experimentally as often as dislocation. The position 
of eversion often misleads the surgeon into a diagnosis of fracture of 
the femoral neck. Konig believes that all everted dorsal dislocations 
result from a breaking away of the posterior wall of the acetabulum. 
Uoberts^ cited a case of hip injury in a woman, aged twenty-six years, 
who had been confined to bed for many months on account of her 

1 New York Jour. Med., 1850, p- 314. 2 Tr. Am. Surg. Assn., xxix. 94. 

' Ibid., 90. 



682 DISLOCATIONS OF THE HIP 

disability. The legs were parallel to each other, the right hip was 
rigid, the leg was shortened, and the foot everted. Upward displace- 
ment of the trochanter measured one and a half inches, and when the 
leg was abducted, the buttock was flattened, but there was no kyphosis. 
All motions were greatly limited, and a diagnosis of old fracture of 
the neck and hysteria was made. A study of the roentgenogram, 
however, showed a dorsal dislocation with eversion, and it was decided 
that the best treatment was to excise the head rather than to attempt 
to replace it in the acetabulum by open operation. This procedure 
was carried out. The head was found resting in a socket-like depres- 
sion deepened by the inflammatory thickening of the surrounding soft 
parts. Mr. Stiles, of Edinburgh, discussing this treatment, stated that 
it was better to remove the whole neck, because it would slip up after- 
ward and an unstable joint would result. The whole neck should be 
removed, and the trochanter should be rounded off and placed in the 
acetabulum in abduction to give a stiff but stable hip-joint. He men- 
tioned two cases so treated by him. The same advice as that given 
under old fractures of the femoral neck may be given here, namely, 
a bony ankylosis may be obtained either to the acetabulum or to the 
ilium when the trochanter cannot be brought into the acetabulum. 

Everted anterior dislocation of the femur must also be differentiated 
by failure to feel the head anteriorly. Fracture is eliminated by the 
rigidity of the leg in the everted position, the pain caused by attempts 
to invert the dislocation, and the recognition of an unbroken con- 
tinuity of the neck verified by the communication of shaft movements 
to the head, which can be felt by the fingers placed over it above th^ 
acetabulum. Flexion of the thigh with inward rotation and adduction 
may bring the head into the customary posterior position, and complete 
reduction can be accomplished by further flexion and rotation with 
traction or pressure downward. The condition of rupture of the outer 
fibers of the Y-ligament may exist without the head assuming the 
position of everted dorsal dislocation. These cases may be recognized 
in the course of the usual manipulative reduction (see Treatment). 
When abduction fails to cause the head to slip into the acetabulum, 
the fulcrum of the Y-ligament fibers being lost, reduction is then 
accomplished by traction forward on the flexed and adducted 
thigh. 

Treatment. — Until Bigelow's epoch-making work on the causes and 
pathology of hip luxations was adopted by surgeons all over the 
world, reduction by manipulation had gained but little recognition. 
Manipulation had been known and used as a means of reduction from 
the time of Hippocrates, and in 1670 Wiseman advocated forcing the 
knee up onto the belly and pressing the head into the acetabulum.^ 
Boulton, Turner, Anderson, and Physick also reported manipulative 
reductions prior to the teaching of Nathan Smith in 1815. These 
men recognized muscle intervention as a greater obstacle than liga- 

1 Quoted by Hamilton, Fractures and Dislocations, 1880, 6th American ed. 



HIP DISLOCATIONS 683 

mentous pull. Reid/ in 1851, advocated manipulation, and Gunn,"^ 
]Moore,^ and others, after experiments on the cadaver, concluded that 
the ligament and capsule were the main obstacles to reduction by 
direct traction. Hamilton himself^ reported 41 cases of hip luxation, 
28 of which were reduced by manipidation on the first trial, 7 on the 
second, -i on the third, and 2 on the seventh. Attempts at reduction 
by direct traction from strong multiple pulleys continued to be the 
general practice, however, with the leg in complete extension. Often 
the reduction did not succeed and when the head was dragged into 
the acetabulum, it was at the expense of rupture of the Y-ligament. 
After Bigelow's publication in 18(59 {The Hip), and his later con- 
tribution,^ the importance of the iliofemoral ligament was accepted, 
and reduction by manipulation became the recognized method in 
all regular luxations. In 1896 Allis*^ made refining changes in the 
manipulations with a view to decreasing the force used and thus 
eliminating tears in the capsule and soft parts and to taking advan- 
tage of the Y-ligament as a fulcrum. 

From the previous description it is understood that the Y-ligament 
is the main obstacle to replacement of the head in the acetabulum 
when the leg is extended, and it is this intact ligament which holds 
the femur in a position of flexion, internal rotation, and adduction. 
The first step in reduction of posterior luxation must necessarily be 
flexion for relaxation of the ligament. Besides relaxing the liga- 
ment, flexion lowers the head of the femur along the posterior rim of 
the acetabulum, and it approaches nearer the tear of exit in the cap- 
sule. The position of adduction and rotation inward of the limb is 
maintained in this maneuver and tends to draw the head somewhat 
from the iliac wall out to the acetabular rim. ^Muscle interposition, 
especially that of the obturator internus, is also removed by this 
position. The three principal methods of reduction are (1) AUis's 
direct method; (2) Bigelow's circumduction, and (3) gravity method 
of Stimson. 

(1) AUis's Method. — The pelvis can be fixed to the floor by means 
of bandages or straps passed through three staples. One staple is 
placed on each side of the iliac crest, and the third is placed between 
the legs in front of the perineum. If the means for this fixation are 
not at hand, Ridlon's method of steadying the pelvis may be used. 
That is accomplished by the operator's flexing the uninjured thigh 
on to the pelvis and against the trunk and strapping it in that posi- 
tion, so that the assistant has something firm to grasp and can hold 
the pelvis easily. 

The thigh is flexed in its position of inward rotation and adduction; 
the Y-ligament is relaxed; the head descends and approaches the rent 
in the capsule. The second step is for the operator to lift the thigh 

' Buflfalo Med. Jour., August, 1851, vii, 129. 

- New York Jour. Med., September, 1848, p. 268. 

3 Ibid., November, 1853, p. 42.'^. 

* Buffalo Med. .Jour., NovemV>er, 1857, and P'ebruary, March, June, 1859. 

•• Lancet, 1878, i, 8G1. * Gro.ss Prize Essay, Philadelphia. 



684 DISLOCATIONS OF THE HIP 

forward with both arms, the pelvis being held fixed by an assistant, 
or by the operator's foot placed across the iliac spine. This maneuver 
is generally sufficient to produce reduction, but if there is any resis- 
tance felt in the lifting and the head does not slip into the acetabulum, 
the thigh is adducted more to relax the capsule and is again lifted. 
If obstacles still persist, slight movement of outward rotation may 
remove them if they are the short muscles and sciatic nerve, after 
which the head can be lifted into the joint. A^ery little force should 
be used, because this method aims to avoid further laceration of the 
articular structures and is not dangerous. 

After the head is in the acetabulum or over the edge of the cavity 
the leg is allowed to extend fully on the flat surface on which the patient 
lies. It must not be forcibly extended. High posterior luxation in 
which the femoral head may have escaped by a tear higher in the 
capsule does not require so much flexion of the thigh for bringing of 
the head near the capsular opening. Consequently the traction of 
lifting is applied before much flexion is made, or with the leg in the 
position found in the displacement. 

(2) Bigelow's Method: Circumduction. — The original description con- 
tained instructions for the use of general anesthesia. By flexion of 
the thigh on the abdomen the same step described in Allis's method 
w^as used, namely: an exaggeration of the adduction and inward rota- 
tion, already existing, to relax the iliofemoral ligament. The femoral 
head was then lifted or jerked upward into position. External rota- 
tion must be avoided in the first motions, as they may rupture the 
Y-ligament and bring the head farther upward and forward or down- 
ward to the obturator foramen, if there is flexion, abduction, and 
traction. Failure to reduce by this manipulation necessitated out- 
ward rotatory movements, the circumduction being performed simul- 
taneously with the forcible lifting, and followed by extension. The 
circumduction made use of the intact Y-ligament as a fulcrum to lever 
the head into the acetabulum after the preceding movements brought 
it to the edge of the acetabulum. Bigelow's second paper^ gives the 
following brief description of reduction: 

^'(1) Flex and forcibly lift. If this fails, 

"(2) Flex and lift while abducting. If this fails, it will be found 
that the rent in the capsule has been so enlarged that the first method 
may now prove successful." 

In making this reduction the surgeon must bear in mind that the 
result is obtained by the force of traction or lifting, and that the cir- 
cumduction is secondary and used only to remove obstacles from 
the path of the head. These rotatory motions must be limited, and 
the abduction must not be forced lest the Y-ligament be torn and 
possibly some other type of dislocation be produced. During the 
course of the rotation the traction on the thigh must be steadily 
maintained. Relaxation of the traction lets the head fall back, pulled 

1 Lancet, 1878. 



HIP DISLOCATIONS 



685 



by gravity and the muscles about the joint, so that a new position 
is estabhshed in the surrounding tissues and the head is not in a posi- 
tion near the acetabular rim, where the surgeon intends it to be when 
outward rotation levers it into the acetabulum just prior to reduction. 
(3) Stimso)is Gravity Method.^— The gravity- method^ aims at reduc- 
tion on the same general principle as the two previously described, 
but places the anesthetized patient face downward with both legs 
hanging over the end of the table (see Fig. 478). The sound limb is 
held horizontally by an assistant, and the surgeon grasps the injured 




Fi(j. 478. — Gravity method of reduction of dorsal dislocation of the hip. (Stimson.) 

leg at the ankle, flexing the knee to a right angle and holding the leg 
in slight adduction. Gravity exerts sufficient force to pull the femoral 
head gradually into place after muscle relaxation occurs. A sand-bag 
and pressure downward back of the knee may be used to aid traction. 
This position simply reverses the lifting traction of the direct method. 
Anterior Dislocations. — In Steinke's collection of 10 cases of hip 
dislocations at the Episcopal Hospital, Philadelphia, in ten years, 
there were 2 anterior, 1 pubic, 1 thyroid, and 8 posterior luxations. 



Stimson, New York Med. Jour., August 3, 1889. 



GS6 DISLOCATIONS OF THE HIP 

The anterior luxations are less frequent than the posterior, and may 
be classified into the following varieties: 

(1) Pubic luxations, including the suprapubic and subspinous and 
the luxations directly upward. 

(2) Obturator or thyroid luxations, the most frequent type. 

(3) Perineal. 

Pubic Luxations. — Causes. — In the general remarks on the mech- 
anism of hip dislocations it is stated that the position of abduction 
causes the neck to impinge against the rim of the acetabulum and the 
greater trochanter of the femur to strike against the ilium. The head 
is thereby levered out^of the joint by a rupture in the lower anterior 
portion of the capsule, because the Y-ligament retains the upper end 
of the femur in its relation to the ilium. The causes are falls on 
the leg, which is abducted and hyperextended, and forcible hyper- 
extension of the trunk on the legs, which remain fixed. A man may 
make a misstep going down a flight of stairs or in walking step into 
a hole and suddenly throw his body backward to save himself from a 
fall while the thigh is abducted and extended. Sudden application 
of trauma on the back with the legs spread apart may likewise produce 
a pubic dislocation. Another cause is that found when a man is 
riding between two cars, sitting on the sill of one with his legs elevated 
on the sill of the other. A s^idden jerk of taking up slack in the train, 
or the application of brakes^ shortens the distance between the cars 
and forces the leg upward against the trunk, causing dislocation. 
The luxation is not the result of direct violence pushing the femur 
upward out of the socket while the leg is extended directly forward, 
but results after a turning of the trunk has been unconsciously per- 
formed to allow for flexion of the leg. The pelvis twists to one side on 
the fixed leg which does not flex by knee action, -and the leg is placed 
in a position of abduction and probable outward rotation, so that an 
anterior dislocation follows. I saw at Mercy Hospital a case of similar 
origin in the service of Dr. Pierce, resulting in posterior luxation. A 
fireman stood on the engine deck, his back to the cab, his thigh flexed, 
and his knee braced against the front of the water tank, which was 
just far enough away to permit the assumption of that position. 
Switch duty was being performed by the engine, and while the fireman 
was standing thus the engine made a cross over which slightly approxi- 
mated the tank to the cab surface and irresistibly pushed the flexed 
femur in slight adduction out of the socket posteriorly. In this 
instance the trunk was fixed and could not rotate to bring the leg 
into abduction, because the man's back rested squarely against the 
flat surface of the cab. 

Pathology. — The capsule is ruptured in the lower anterior portion, 
and the head escapes in front of the joint and comes to rest on the 
superior ramus of the pubis, the extent of its excursion toward the 
symphysis varying with the amount of force and the stretching or 
laceration of the ligaments. Tearing of the Y-ligament is unusual, 
and the ligamentum teres is generally pulled off at the insertion into 



HIP DISLOCATIONS 687 

the femoral head. The head of the bone pushes the muscles and 
vessels in front of it and rarely injures them. The external rotators 
of the hip are drawn tightly over the acetabulum. Two cases of 
injury of the femoral vein have been reported in pubic luxations. 
The sciatic nerve is entirely removed from the possibility of injury, 
but the anterior crural nerve may be pressed upon or stretched so 
that anesthesia develops in its distribution. Open dislocation has 
been reported^ either from protrusion of the head by pressure from 
within outward, or by laceration of the soft parts in front of the joint 
from the hyperextension. In a very few instances the head of the 
bone has been driven far upward into the groin and in one case^ com- 
plicated by fracture of the femur in reduction attempts, the head was 
found at autopsy in a position between the psoas and rectus muscles 
above the iliopectineal eminence. Extreme anterior positions may 
cause vessel rupture, and that possibility must be considered in 
examination of the forward luxations. 

Symptoms, — ^^Yhen the head lies in an anterior position on the 
iliopectineal ridge, it can be palpated on the groin below Poupart's 
ligament, and the femoral artery lies stretched over it or on the inner 
side. Injury of the femoral vessels is rare because of their position 
anterior to the joint, which causes them to be lifted up by the tense 
muscles beneath at the instant of dislocation. The vessels are 
approached by the head in anterior dislocations alone, and to cause 
that displacement the leg must be flexed and abducted, a position 
which stretches the muscles forming the floor for the vessels with 
the previously mentioned result (Fig. 479). The leg is abducted 
slightly and the foot is turned outward. The amount of abduction 
of the upper part of the limb depends on the amount of displacement 
of the head inward along the pubic ramus; the farther inward it lies, 
the greater the abduction of the thigh. Attempts to adduct the leg 
meet with the firm resistance offered by the intact Y-ligament, which 
holds the femur to the inferior iliac spine, and by the pressing of the 
head against the pubic ramus. Abduction and flexion are possible, 
and the patient may be able to walk as the leg is generally in a posi- 
tion of full extension. The whole leg appears lengthened, and there 
is flattening over the trochanter, which has lost its normal prominence. 
Karely the head is pushed up over the edge of the pelvis beneath Pou- 
part's ligament or bursts through it. Wide displacement means 
complete rupture of the ligament and an unstable position. 

Treatment. — Traction exerted on the leg in a position of abduction 
and extension followed by adduction and pressure against the head 
has resulted in successful reduction of pubic dislocations. But since 
it may cause injury to the vessels, a manipulation has been worked 
out which relaxes the Y-ligament and psoas muscle and does not put 
too much strain on the intact posterior portion of the capsule, which 
is used as a fukruni. When the head rests on the pubic ramus and 

' Chcever. Stiin.son, Goldsmith. 

= Verneuil, Bull. Soc. de Chir., Pari.s, 1870, xi, 145. 



688 



DISLOCATIONS OF THE HIP 



the thigh is flexed, the Y-ligament relaxes, but the head of the bone 
instead of descending on the surface of the pubic ramus may be 
pushed farther up under Poupart's Hgament, being held by the pos- 
terior portion of the capsule. To overcome this obstacle to reduction 
and to avoid damage the operator draws the limb down by traction 
in its position of abduction until the head is beginning to descend 
from its pubic position and he knows that the posterior portion of 
the capsule is tense. Then he makes direct pressure downward on 
the head of the femur to hold it in the position gained by traction 
while partly flexing the thigh. This maneuver will often cause the 
head to slip into the socket. If it does not, the pressure over the 
head is increased, and the thigh is rotated inward until reduction 
follows. 




Fig. 479. — Pubic dislocation. Note the head in front of the acetabukim on the pubic 
ramus and the abducted position of the leg. 



Subspinous luxation and luxation directly upward are two exag- 
gerated types of anterior dislocation. The femoral head passes from 
a suprapubic position upward and backward until it lies above the 
acetabulum, and the term supracotyloid or subspinous is applied 
to this secondary position below the antero-inferior iliac spine. 
Two distinct groups of subspinous luxation may be anticipated — one, 
a secondary position following anterior luxation, and the other, a 
primary displacement from direct upward forcing of the femoral head. 
Stimson^ reported a case of direct upward dislocation caused by a 
man falling beneath a heavy case. The thigh was extended and 
slightly abducted and the foot markedly everted. The skin over the 
upper thigh had been torn by overstretching, and the head of the 
femur lay an inch directly below the anterior inferior iliac spine. 

1 Ann. of Surg., December, 1892. 



HIP DISLOCATIOXS 689 

In either group wide laceration of the capsular ligament must be 
present, and the upper fibers of the Y-ligament are also torn. Autop- 
sies have been performed in a few instances of this luxation and 
these findings confirmed. There is eversion of the foot, some shorten- 
ing of the leg, the head is palpable below the spine, and adduction 
and internal rotation are lost. Abduction and flexion are possible 
but painful, and the luxation may be compared to the everted dorsal 
in its clinical findings and pathology. 

Treatment adopting the ride of attempting reduction over the 
path which caused the luxation by placing the limb in the position 
it assimied at the time of injury, does not apply well here on account 
of the extensive laceration about the hip-joint. Reduction is accom- 
plished by traction on the thigh in a position of partial flexion, an 
assistant making direct pressure downward and backward on the head 
of the femur during the traction. 

Obturator, or Th3rroid Dislocations. — Luxations into the thyroid 
depression are the most common of anterior displacements. The 
basis for division of hip luxations into anterior and posterior has been 
previously given, based on the excursion of the head after it leaves 
the usual rent in the inferior portion of the capsule. A position of 
abduction and flexion of the thigh at the time of luxation causes the 
head to pass forward and downward toward the obturator opening. 

The causes are falls with the legs spread apart or heavy weights 
pressing against the lumbar spine when the thigh is abducted and flexed. 

Pathology. — The capsular tear need not differ much from that found 
in posterior dislocation. It occurs on the inner lower anterior side 
and is near the acetabular insertion. The Y-ligament is relaxed; the 
head passes forward and inward and rests in the obturator foramen. 
The ligamentum teres has been found completely torn off or simply 
stretched without laceration. Muscle laceration and complications 
are similar to those of posterior luxations (see Fig. 480). 

Symptoms. — The untorn Y-ligament holds the femur and thigh 
abducted, everted, and partly flexed. There is some apparent length- 
ening of the injured limb if both are brought into a line of com- 
plete extension, because the pelvis tilts upward to accommodate the 
forced extension of the thigh. Marked restraint in adduction and 
extension is caused by the impingement of the great trochanter held 
by the Y-ligament on the lower acetabular border, and not so much 
by the pressure of the head in the obturator foramen. The greater 
trochanter is concealed on the outer surface of the hip, which is flat- 
tened and relaxed. There exists a depression between the ilium and 
femur from relaxation of the fascia and muscles, favored by the 
inward displacement of the trochanter. The head of the bone can 
sometimes be palpated by deep pressure of the examining finger down 
toward the thyroid depression, but the trochanter is hidden even 
when rotatory movements attempt to locate it. If the displacement 
is marked, the head slips deep down into the obturator foramen, and 
the trochanter slides into the acetabulum (Fig. 481). 



GOO 



DISLOCATIONS OF THE HIP 



Everted thyroid luxation is a rare form resulting from further 
rotation of the femur outward, which brings the head into more promi- 




FiG. 480. — Obturator dislocation. (Bigelow.) 




Fig. 481. — Thyroid dislocation looked at from the rear. 



nence anteriorly and carries the trochanter farther inward until it 
rests in the thyroid depression. The rotation causes the Y-ligament 



HIP DISLOCATIONS 691 

to become twisted around the neck of the bone. Here the trochanter 
lies against the inferior surface of the horizontal ramus of the pubis. 
The everted anterior type may also be a sequence of pubic dislocation. 
\Yhen it follows a luxation originally thyroid, the femoral head points 
outward, the trochanter is pressed in against the thyroid depression, 
the toes point backward, and the internal malleolus is turned com- 
pletely outward. 

An additional type of dislocation which lies just below the acetabular 
margin midway between the thyroid depression and the ischium has 
been called infracotyloid dislocation. In 1905 Niederle collected 
20 cases of this type.^ The condition probably presents the early 
stage of many hip luxations, when the head of the bone has emerged 
from the inferior portion of the capsule and its further excursion 
into a position anterior or posterior to the line drawn from the antero- 
inferior iliac spine has been checked. Continued action of the caus- 
ing violence, with the thigh brought into a position of adduction 
and rotation inward, will lead to an ordinary posterior luxation, and 
if outward rotation and abduction of the thigh follow, a thyroid 
dislocation is expected. The cause of infracotyloid dislocation is the 
same as dorsal luxation, the head lies midway between the two points 
mentioned, and the intact Y-ligament holds the hip slightly flexed, 
either in eversion or inversion. ^Manipulations ma^^ extend the cap- 
sidar and muscular tear and convert the condition into a true anterior 
or posterior luxation. 

Treatment. — Reduction may be accomplished by the surgeon 
bringing the head up to the capsule opening and lifting or pulling it 
into the socket. This result is accomplished by his flexing the thigh 
and rotating it still farther outward to relax all the joint structures. 
He then makes traction in the direction of the long axis of the leg to 
bring the head nearer the socket, the knee being flexed, and follows 
this by inward rotation and extension of the leg to a normal position 
as reduction ensues. If this fails, he may change the last step to an 
outward rotation or a rocking of the head in and out, using the outer 
branch of the Y-ligament as a fulcrum to lever the head upward into 
the socket. A towel or wide band applied around the upper part 
of the thigh may be used for angular traction outward in connection 
with the traction made by the operator in the long axis of the leg. 
An assistant's fingers pressing on the head may be substituted for the 
accessory lateral traction, the fingers acting as a fulcrum on which 
the bone head is levered back into the socket. Bigelow advised 
flexion and adduction of the thigh to convert the dislocation into a 
dorsal position and subsequent reduction used by the means prescribed 
for that position. This entails further and unnecessary capsular 
laceration and will not be needed unless other methods fail entirely. 

In all the described movements too much flexion must be avoided, 
as that pushes the head farther into the thyroid depression by increas- 

1 Centraibl. f. Chir., lUOo, p. 31. 



692 DISLOCATIONS OF THE HIP 

iiig the tension of the Y-Ugament. Shght forward traction is the 
force needed to lift the head near the capsular tear, rather than any 
backward push, which may easil}^ convert the luxation into a dorsal 
position. For everted thyroid luxation, when the head has turned 
outward and the trochanter lies on the thyroid depression, the limb 
must be rotated gently inward that the Y-ligament may be unwound 
from the neck of the bone until a position of ordinary thyroid or pubic 
luxation is reached, after which the method of reduction described 
for that position may be employed. 

Perineal Luxations. — But few instances of this type of anterior hip 
dislocation have been reported. The causes of perineal luxations are 
probably the same as those of the thyroid dislocations, with the 
employment of greater force in extreme abduction. The head is 
forced out of the capsule on the anterior surface and is carried well 
inward and forward of the obturator depression until it lies in the 
perineum. 

The pathology includes a wide tearing of the anterior and lower 
portion of the capsule and probably also of the Y-ligament. The 
head has been pushed inward and forward and may press upon the 
urethra or rupture the perineal skin. 

The thigh is flexed and usually extremely abducted beyond a point 
to which it is possible to abduct the sound limb. Palpation of the 
perineum discovers the femoral head at a slight distance from the 
midperineal line anterior to the anus. The leg may be in inversion 
or eversion, or the position of the luxation may be unstable on account 
of the extensive ligamentous laceration. Attempts at extension and 
adduction of the leg cause pain and are opposed, but some flexion and 
rotation of the thigh are possible. 

Reduction is made by direct traction in the long axis of the thigh 
in the extreme abducted position, aided by pressure on the head of 
the bone backward toward the joint socket. A position of thyroid 
dislocation may result and flexion of the thigh with outward traction 
causes reduction. A towel slung around the upper part of the thigh 
may make extra traction outward on the upper part of the femur 
and assist in reduction. Sometimes, but rarely, rocking movements 
are needed to push the head back through lacerated capsule and 
ligament. 

Complication of Hip Dislocation. — Complications are unusual and 
have been mentioned under the different types of luxation discussed. 
Muscle rupture is a likely occurrence in any of the exaggerated forms 
of luxation or in violent and unwise attempts at reduction. High, 
posterior luxations may tear the glutei, and anterior luxations into 
the thyroid depression or onto the pubis may rupture the adduc- 
tors of the hip and the pyriformis. Small muscle tears are expected 
in any luxation, and no special treatment is indicated unless the torn 
muscle acts as an obstacle to reduction. In exaggerated luxations 
a longer period of immobilization of the joint is demanded for the 
sake of capsular repair, and the muscle injury is repaired during 



HIP DISLOCATIONS 693 

this period. Healing by scar formation probably leads to a slight 
unrecognized difference in function later. 

Rupture of the femoral vessels is very rare. It occurs only in 
anterior and open luxation. The prognosis is grave. 

The sciatic nerve is injured only in posterior dislocations. It may 
be caught against the neck of the femur in the dislocation primarily, 
or it may be picked up and stretched over the bone by attempts at 
reduction. A few instances of rupture and entanglement of the 
nerve have been seen at operation and autopsy. Slight contusion 
may result in a traumatic neuritis with paresis and pain which are 
temporary, lasting but a few weeks or months. Continued stretching 
of the nerve from incarceration will cause permanent paralysis in its 
distribution, and rupture will, of course, give immediate and lasting 
symptoms. Allis records one case of posterior dislocation which was 
seemingly reduced as far as the position of the head could be deter- 
mined, but the leg still maintained a slight amount of flexion, and 
there was numbness on the dorsum of the foot. Months later, in 
demonstrating hip luxation on the cadaver, he encountered the same 
objective findings and made an immediate dissection, finding the sciatic 
nerve wound about the femoral neck. 

Reductive attempts by circumduction are the efforts w^hich are 
likely to pick up the nerve and cause it to slip over the bone. The 
head seems to enter the acetabulum, but a slight degree of thigh and 
leg flexion persist, and there is pain when the leg is passively extended. 
If a looping up of the nerve can be diagnosed, the treatment must 
consist either in redislocation by manipulation or an open operation 
for freeing the nerve by sight. The femur is carried into extreme 
adduction by the bringing of the affected thigh up across the abdo- 
men, the leg flexed on the thigh. Reduction is again attempted, but 
if the nerve persists in becoming entangled, open operation is the best 
recourse. Allis has suggested that after redislocation the nerve should 
be held taut through an incision in the popliteal region and reduction 
made. The surgeon must recall that the nerve is very large near the 
hip-joint, measuring an inch and a quarter in width, so that it may 
easily be mistaken for other structures and can offer resistance to 
reduction. 

Fractures in the hip region are rare complications of luxation. A 
very few fractures of the head have been reported in connection 
with dislocation. Fracture of the femoral neck may occur at the 
time of dislocation, or, as in most instances on record, it has followed 
attempts at reduction. The prognosis as to life is poor in these cases, 
because the violence has been extreme. Reduction by direct pressure 
and manipulation is reported, but under present surgical conditions, 
an open operation which would fix the head onto the fractured neck 
after replacement in the acetabulum would be the treatment of choice 
>ee Fractures of the Femoral Neck). Shaft fractures are also uncom- 
mon accompanying hip dislocation. Hamilton, in his last edition, 
collected 4 eases. Allis reports having seen 3 cases. In the last year 



694 DISLOCATIONS OF THE HIP 

at the Cook County Hospital we have had 1 ease. Treatment is 
first (Hrected toward reduction of the hixation and subsequent care 
of the fracture. Bigelow suggested the use of coaptation splints applied 
firmly around the thigh to hold the fractured bone and manipulation 
following directed mostly toward flexion. The management of the 
dislocated head locally, the surgeon grinding it into the hip socket by 
digital pressure, would complete the efforts at reduction. Failure of 
manipulation must be followed by immediate open operation. The 
head could be reduced, and if this were wished, the bone fixed at the 
fracture site by an internal splint. Two incisions would be needed 
when the fracture was located at some distance from the joint. 

Associated pelvic fractures, especially those in connection with 
central dislocation of the femur, have been discussed under the heading 
of Fracture. The prognosis is grave. 

Accidents in, and complications after, reduction are now rare. 
Formerly heavy mechanical traction by the use of pulleys sometimes 
caused fracture of the femur and increased the opportunity for sup- 
puration about the hip by tearing the soft structures and increasing 
the hematoma. Suppuration may follow an easy reduction, the source 
of the infection arising from bacteria in the blood. One must avoid 
violent rotation and extreme abduction of the femur to guard against 
these accidents. 

Prognosis and After-treatment. — The prognosis of reduced uncom- 
plicated hip luxations is good, but little disability following most cases. 
In Steinke's recently dislocated 10 cases referred to, the hospital 
stay averaged from three to forty-seven days. One case ended fatally 
on the third day, the others with one exception of probable nerve 
injury, gave excellent results, upon examination from two months to 
four years after. In the last two years at Cook County Hospital 
the stay has varied from one day to two months. In usual disloca- 
tion it is sufficient to place the patient in a bed and support the leg 
by sand-bags or a padded Liston splint. In exaggerated positions 
of the head with extreme laceration of muscles and capsule a Buck's 
extension with ten or fifteen pounds' weight may be applied for a 
week or ten days. If there is a tendency to the development of an 
arthjitis, the leg can be placed in a circular body plaster cast and left 
there two to three weeks. A position of abduction is maintained. 
The general rule is that the sooner after luxation the reduction occurs, 
the shorter the convalescence is. In a small proportion of luxations 
the joint remains tender, and motion is restricted, because of muscle 
laceration or a secondary arthritis. When reduction is not performed . 
soon after luxation, it becomes more difficult to accomplish, and the 
limb does not support body weight when it is inverted and adducted, 
as in posterior luxations. A pseudo-acetabulum develops about 
the head in its new position, and a compensatory scoliosis of the 
spine and tilting of the pelvis may permit the foot to rest on the 
ground and the limb to be used in locomotion. A lift on the sole of 
the shoe may aid in walking, but these legs tend to become progres- 



HIP DISLOCATIONS 695 

sively shorter, and really belong to the operative class when irreduci- 
bility is first demonstrated. Anterior dislocation rarely gives shorten- 
ing, and when a new socket forms about the head of the bone, the 
limb may become serviceable even without a crutch or cane. 

Old dislocations of the hip are seldom seen. Boehnke's case of a 
three-year-old boy was found unreduced after being three months in 
a cast. It was reduced by open operation. Reduction may be suc- 
cessful through manipidation and traction, but it is a difficult task, 
and fracture of the femur is a likely complication. Prollet,^ in a col- 
lection of 46 cases, found that in 11 failures of reduction there were 
4 deaths and 8 fractures resulting. Dollinger^ has had a large experi- 
ence with 22 cases, only 4 of which were successfully reduced by 
manipulation. Although there are reports of cases reduced by manipu- 
lation after months of time, I doubt them very much. Bollinger's 
longest case out of the socket' was nine weeks. If the roentgenogram 
shows bony proliferation or partial ankylosis, manipulative attempts 
will surely fail and may lead to grave complications. The age of the 
patient — children offer a better prognosis — and a tendency to osteo- 
arthritis must be considered. Ankylosis may follow manipulative 
reduction. 

If at the present time the position of the limb is unhappy, functional 
loss is great, and the roentgenogram shows any bony interference, 
the choice of treatment is arthrotomy and open reduction. For pos- 
terior luxations an incision is made from the posterior inferior iliac 
spine to the base of the greater trochanter. All connection of the head 
to the pelvis is cut through after the head is found lying under the 
gluteus maximus. The thigh is then brought into strong inward 
rotation and flexion to remove the neck and shaft from the approach 
to the acetabulum. Over the acetabulum are found stretched the 
obturator internus, the gemelli, and the pyriformis. These muscles 
are pulled upward, the acetabulum is cleaned out, and the head is 
levered in by circumduction. In the anterior luxations, the access 
to the acetabulum is covered by the trochanter and the muscles men- 
tioned. The muscles are retracted downward, and the acetabulum 
is cleared. Flexion and rotation inw^ard of the thigh removes the 
trochanter from its blocking position, and the head is subsequently 
levered in, first being freed by dissection from surrounding tissue, 
if it is adherent. It may be necessary in some cases to resect the 
head, because it has been comminuted, or because of the intense 
adhesion. In 4 old posterior luxations, Bollinger reduced 3, one of 
three and a half months' standing. The fourth necessitated resection 
of the head. In 5 old anterior luxations 2 heads were resected, 2 were 
reduced and on 1 an osteotomy (subtrochanteric) was performed 
that a better position of the limb might be obtained. Of the 17 
arthrotomies detailed in this report, 12 resulted in reduction, 4 in 
resection of the head, 1 in osteotomy, and 1 in death. Of the 12 

1 Th^se de Lyon, 1903. 

2 Ergebnisse der Chir., iii. 



G96 DISLOCATIONS OF THE HIP ' 

repositions 5 suppurated, 6 healed per primam. Dollinger prefers | 

the open reposition and considers that children offer the best prog- . 

nosis. I 

Cleaning the acetabulum may result in subsequent ankylosis. 

When this condition is feared by the surgeon, the head should be | 

rounded off and a fat fascial flap interposed, as in arthroplasty. If I 

the head is resected, an ankylosis to the ilium in a position of abduction ; 
is preferable to a movable weaker joint. 

x\n old luxated hip- joint which bears weight and permits some 

motion will often improve in function, and the case must be studied j 

from all sides before the patient is subjected to operation. Infection j 

and ankylosis without suppuration are the foes of operative procedure, ) 

but position can be improved, and in skilled hands these dangers are j 
minimized. 



CHAPTER XXIV. 
FRACTURE AND DISLOCATIONS OF THE PATELLA. 

FRACTURES OF THE PATELLA. 

Ix my collection of fractures at the Cook County Hospital, 
Chicago, fractures of the patella equal L67 per cent, of the total 
number. ^lore than twice as many cases are found in men as in women, 
most instances occur in the fourth decade of life, and very few are 
open fractures. Scannell,^ in a tabulation of all fractures in the Boston 
City Hospital for forty-two years found the patella broken in 668 
cases out of a total of nearly 39,000 fractures, to which he added 
seven years of further records, bringing the total of patella fractures 
to SS2, of which 871 were closed and 11 were open. This injury is 
rare before fifteen years of age, as the bone is not fully formed until 
after puberty, probably not before eighteen years of age. 

Causes. — ^The causes are of two kinds, direct violence, as in a blow 
or fall on the patella, or indirect violence from an unexpected forcible 
contraction of the quadriceps femoris muscle or sudden flexing of the 
leg with this muscle in strong contraction, as in case of a foot caught 
between immovable objects and a sudden pushing over of the body 
into a sitting posture while effort is being made to stand erect. Lon- 
gitudinal cracks or breaks in the bone are undoubtedly caused by 
direct violence, as a smart tap on the knee with the leg in part flexion, 
or a similar trauma received by the striking of the knee against a 
heavy object or sharp edge in walking, the blow being usually received 
with the leg in partial flexion (Fig. 482). Falls or direct violence also 
account for the incomplete fractures or the complete type without 
separation, but the greater percentage of all breaks with the customary 
transverse line of fracture in the lower portion are due to indirect 
violence. Definite history at the time of accident is difficult to obtain 
because of the excitement or the pain, and as most of these injuries 
immediately result in a fall, the patient naturally ascribes the whole 
trouble to the fall. Those cases in which the damage is sustained 
by a person in a squatting position or by known direct violence are 
about the only ones which give a clear history. Falls on the knee, or 
both knees, are common, and yet we do not find many resulting 
in patellar fractures, nor are there many instances of simultaneous 
fracture of both patelliP, which would be expected if direct violence 
were the usual cause. 

' Boston Med. and Sury. Jour., Xoveniber 15, 190G. 



()9S FRACTURE AND DISLOCATIONS OF THE PATELLA 



Steinke^ reported 2 cases of simultaneous fracture of both patelLe 
and collected and analyzed all the cases in the literature up to that 
time, 44 in all, of which 28 mentioned the manner of fracture. This 
was found to be indirect violence in about two-thirds of the cases. 

With the leg semiflexed the patella lies at the highest point of the 
condyles of the femur in a position of weakness and non-support on 
the intercondyloid fossa, as shown in the figure (Fig. 483). Sudden 

strain from flexion of the leg or con- 
traction of the quadriceps will thus 
tend to snap the patella and tear the 
ligaments. 

Blows which cause cracks in the bone 
or complete subaponeurotic fracture 
without separation, result in predispo- 
sitions to subsequent injury of the same 
character or complete fracture by in- 
direct violence, as in a case reported 
by me^ (Fig. 484). 

Pathology. — Transverse or oblique 
fractures are of most frequent occur- 
rence when the cause is indirect vio- 
lence. Corner^ gives this finding in 83 
per cent, of cases, and Kroner^ found 
longitudinal fracture in 3 cases, oblique 
in 8 cases, transverse in 166, stehate in 
6, and comminuted in 22 of those ana- 
lyzed by him. This form of fracture 
is for the most part situated in the lower 
half, as the triangular-shaped patella is 
the most common, but it may be found 
at any site in the bone, involving its 
whole diameter or merely one corner 
(Fig. 485) . The line of fracture may 
be straight through the substance of 
the bone, or pass in an oblique direc- 
tion or be step-like or curved, the 
line of one surface lying at a differ- 
ent level from that of the other with 
a sharp right-angled or curved plane of separation. If lateral press- 
ure or force has been combined with the indirect violence freakish 
lines of displacement result, involving but part of the bone in its 
anteroposterior plane and yet causing complete separation in the 
longitudinal axis. In longitudinal fractures, complete separation 
may not be present; if it is present, one fragment may be dislocated 




Fig. 482.— Fracture of the patella 
from direct violence caused by an 
object striking the bone. The upper 
outer quadrant is broken off and 
carried upward and outward by 
the force and contraction of the 
vastus muscle. 



1 Ann. of Surg., Iviii, 510. 

2 Surg., Gynec. and Obst., May, 1911, p. 469; Wegner, Deutsch. Ztschr. f. Chir., 1900, 
Bd. Ivii, S 157. 

3 Ann. of Surg., lii, 707. '' Deutsch. med. Wchnschr., xxxi, 996. 



FRACTURES OF THE PATELLA 



699 



out of its position laterally (Fig. 486). All of those that I have seen 
involved the outer portion of the bone, and the outer fragment was 
displaced outward, pulled by the vastus externus insertion. If the 
fracture line passes through the frontal plane and is complete with 
anterior and posterior fragments, one of these may be displaced 
laterally, but the mechanism in these cases is more apt to be a primary 
dislocation with subsequent splitting of the bone and a return to normal 
position of one fragment. 





Fig. 483. — Position of non-support of the patella on the intercondyloid notch. Com- 
plete transverse fracture of the patella without much displacement. , The patellar 
ligament has torn out the tibial tubercle, instead of being itself ruptured, and there is 
a eoexistant Schlatter's sprain. 

Comminuted, stellate, and some oblique fractures are due to direct 
violence and are of infinite variety (Fig. 487). They may follow 
simple transverse fracture with a subsequent fall furnishing direct 
violence to comminute the bone. The right patella is more frequently 
fractured than the left. 

Displacements.— In the complete subaponeurotic type or in instances 
of a crack without tearing of the periosteal covering, the separation 
may be practically nil. Displacement depends entirely on the con- 



700 



FRACTURE AND DISLOCATIONS OF THE PATELLA 



comitant rupture of the fibrous aponeurotic investment of the bone 
and the tearing of the lateral ligaments and synovial membrane of 
the knee-joint. The bone may suffer a comminuted or stellate frac- 
ture, and thus be split uj) into many fragments which do not separate 
on account of the intact covering. The degree of displacement in 
transverse or oblique fractures in which the periosteal covering is 
torn is further determined by the extent of this tear laterally into the 
structures of the joint. Immediately after the accident, a transverse 
fracture will show from one-quarter to one inch separation between 




Fig. 484. — Complete subaponeurotic patellar fracture without separation of the 
fragments or appreciable capsular tear. 



the fragments, the sulcus being plainly seen and palpated. Should 
hemarthrosis with distention occur, this separation becomes greater 
in a short time. While the lower fragment is held securely by the 
patellar tendon, the upper fragment tends to retract further through 
contraction of the quadriceps muscle, which has lost its anchorage to 
the tibia. The lower fragment is rotated a little so that its broken 
surface tilts forward, while the upper fragment usually takes the 
opposite displacement, its broken surface tending to turn toward the 
joint cavity or be rotated posterior (Fig. 488). Any modification of 
these positions is found, even the reverse of that given, because of 



FRACTURES OF THE PATELLA 



701 



direct violence or the incarceration of the fragments in shreds of 
periosteiun. 

Angular displacements laterally with no great separation are due 
to uneven tearing of the capsule, one side giving way completely, 
the other holding by enough tissue to pull the fragments into that 
position. Anterior or posterior angular displacement may come 
from the same cause, the fibrous layer in the front tearing while the 
posterior layer and synovial surface remain more or less perfectly 
intact and hold the posterior margins of the bone closer together. 





Fig. 485. — Usual type of patellar frac- 
ture, transverse near the lower third. Note 
the tiltingof the fragments which are drawn 
by their respective attachments. 



Fig. 486. — Longitudinal patellar frac- 
ture. Slight outward displacement of 
the small fragment pulled by the capsule 
and vastus externus muscle. 



It should be remembered that the pressure of bandages or pads can 
also cause the.se angular displacements, in which positions the bone 
may heal. I recall one such case in a workman who had been 
recently treated by the operation of wiring. The wire had com- 
pletely encircled the bone, brought the fragments into apposition and 
resulted in strong union, and yet he could not flex the leg more than 
'.]() degrees. Examination showed firm union, with no trouble in the 
joint, but beyond 30 degrees a firm opposition to flexion, which was 
explained when a lateral view by roentgenogram was studied. The 



702 



FRACTURE AND DISLOCATIONS OF THE PATELLA 



operator had secured contact along the Hne of fracture, but the apposi- 
tion was miperfect, inasmuch as the upper fragment was tilted at 
a slight angle so that its fractured surface pointed somewhat backward 
and its posterior margin overhung that of the lower fragment. When 
attempt to flex the leg was made this projecting edge of the upper 
fragment impinged on the femur and prevented further flexion. 

More important than that of the bone is the injury to the capsular 
structures. By this, as previously mentioned, the amount of displace- 
ment of the osseous fragments is governed. It is found in aU cases 





Fig. 487. — Comminuted fracture of 
the patella. Note the several frag- 
ments and the mde separation indi- 
cating extensive capsular tear. 



Fig. 488. — Lower fragment of frac- 
tured patella rotated to tip forward 
a little. Upper fragment looks back- 
ward toward joint. 



of complete fracture and probably also in incomplete fracture, most 
cases of which are not opened for verification. The tear in the perios- 
teal fibrous covering is generally at a different level from that of the 
fracture, so that when the fragments separate the edges are covered 
on at least one side by the fringe of the fibrous tissue which falls 
between. Macewen^ first demonstrated this in 1887. It may be 
very ragged and shredded or have a distinct sharp line of tear, as if 
it had been cut. Extending laterally in direct continuity are the 
tears in the lateral ligaments which may reach down toward the back 



Ann. of Surg., li, 177. 



FRACTURES OF THE PATELLA 703 

of the knee-joint. The ligaments can be separated for several inches, 
the tear involving the less elastic fibrous structures and sparing in 
part the more elastic synovial membrane. Knowledge of this pathology 
is essential to proper treatment and prognosis. If the osseous fragments 
have lying between them a thick fibrous tissue one cannot hope to 
obtain bony union unless that is removed. If the lateral ligaments 
and synovial membrane are torn and separated they will tend to 
remain apart even if the leg is put in complete extension and pressure 
is made on the fragments of bone to approximate them. They con- 
tract and are bulged out by the blood with which the joint is distended. 
Healing by cicatrix is a long and slow process. When motion is 
attempted this cicatrix will prevent full freedom ; moreover, the fibrous 
union obtained between the bone fragments may stretch, and there 
results a knee weakened and unstable, both in its patellar and liga- 
mentous relations. Blood in the joint is almost constant, especially 
when the capsular structures are torn or direct violence has been 
sustained. This causes distention, and the clots bulge up between 
fragments of bone or ligaments. Organization of the clots may lead 
to a fibrous ankylosis, or, if infected, to pyarthrosis and subsequent 
stifi' joint. 

One further point in the pathology which must be clearly under- 
stood, refers to the anatomy of the quadriceps extensor insertion 
and the placement of the sesamoid patella in this tendon. The rudi- 
ments of the patella appear about the tenth week of fetal life, and 
ossification commences from one centre, usually about the third year. 
This ossification may be tardy in its onsets and the bone may 
remain small, so that a rudimentary patella results. This is very 
commonly associated with other congenital defects which involve 
the quadriceps, dislocation of the hips, or defects in development of 
fingers and toes.^ Pearson^ reported 3 cases of congenital defects 
of both patellae which were all related, and other men have recorded 
instances of congenital absence of this bone.-^ Congenital absence or 
lack of development is always associated with impaired function, and 
as a rule the upper end of the tibia and the femoral condyles are well 
developed, but the tendinous insertion of the quadriceps may be a 
fault, or the knee may be subluxated, or there may be some other 
associated congenital deformity. Thorndike^ collected 50 cases of 
congenital absence or tardy development; 29 of these were bilateral 
21 unilateral (Figs. 489 and 490). 

The non-development of the patella is caused most frequently by 
faulty position, either from congenital luxation or malinsertion of the 
patellar tendon, which deprives the quadriceps insertion and the 
bone of a normal amount of stress and functional irritation that are 
necessary for full development. The sesamoid bone, following the 

1 Bogen, Ztsf:hr. f. Orthop. Chir,, 1906. 2 Lancet. 1899, i, 22. 

3 Wuth, Revue d'Orthopedie, 1899, x, 3-38; Senftner, Arch. Pediat., New York, 1904, 
xxi, 837; Heine, Berlin klin. Wchnschr., xli, 498. 

* Tr. Am. Orthop. .\ssn., Philadelphia, 1898. xi, 337. 



'04 



FRACTURE AND DISLOCATIONS OF THE PATELLA 



rule of all sesamoids, is developed in active tendons which are sub- 
ject to much pressure and trauma in their action over a joint. The 
more the bone is exposed to these conditions the larger and more 
protective it becomes, for it acts as a defense to the articulation, 
distributing the force of trauma to which the knee is constantly 
exposed, over a wider area than if it were not present. It also acts as 
a pulley for the leverage action of the quadriceps, keeping its tendon 
spread out and giving better surface action for extension power around 
the condyles. 





Fig. 489. — Unusual development of the 
patella. There was no history of trauma 
and the main portion of the bone retained a 
normal outline. The secondary mass was dis- 
tinctly palpable and the discovery of the 
bipartite character was incidentally made by 
the roentgenogram. This may be a case of 
two centres of ossification which have fused. 



Fig. 490. — Anteroposterior view 
of Fig. 472. There is no evidence 
of fracture in the body of the 
patella. The secondary mass 
has an outline which resembles 
the knee-cap. 



Eighteen cases of congenital absence of the patella were collected 
by Little, and Rubin^ has added 3 more, all occurring in members 
of the same family. 

Some connection between absence or incomplete development of 
the thumb nails and patellse seems to exist. Eubin's 3 cases suffered 
no inconvenience from the lack of patellae and the only explanation 
of the condition which could be offered was a common rickety history. 

In acquired absence of the patella, following operation for its disease 



Jour. Am. Med. Assn., June 19, 191i 



FRACTURES OF THE PATELLA 705 

or fracture, this protection is lost, and though it may seem luineces- 
sary for useful function in walking, there is always loss of power after 
its removal, even if the quadriceps tendon has been carefully closed 
over the gap bv plastic operation. If removed subperiosteally it 
may regenerate. Grubal^ reported a case in which the patella was so 
removed for tuberculosis, and after one year it had reformed, slightly 
larger than normal, and the patient had a slight limp in walking. 
Heineck- collected 21 cases of removal of the patella, 7 of which were 
on account of fracture, and concluded that all were followed by func- 
tional impairment. 

^luch of the functional change depends on the condition of the 
reserve extensor power of the leg, that is, of the expansions of the 
tendinous bands of the vastus externus and internus that pass to the 
sides of the patella and are not inserted directly over it. If the patella 
were carefully lifted out of its bed and these fibers and the lateral 
bands of the fibrous capsule were not disturbed, one would anticipate 
little functional loss and a possible regeneration of the bone. This 
is the pathology of those cases of fracture, often with comminution, 
where there may be as many as ten fragments with some separation 
and relatively little loss of function, the patient being able to walk. 

In comminuted fracture with laceration and opening of the joint 
separated bone fragments may drop down into the joint and demand 
removal. 

Resultant deformities after fracture are: 

(a) Atrophy of the quadriceps from prolonged immobilization, 
because the condition resulting from the fracture prohibits use of the 
muscle, or because the patient does not cooperate to obtain flexion 
and institute active use of the leg. 

(b) Adherence of the upper fragment to the condyles of the femur. 
This condition, fortunately not frequent, leads to great loss of func- 
tion. The lower fragment rarely becomes adherent, but in the healing, 
ossification may extend down into the patellar ligament and impair 
the joint function (Fig. 491). 

(c) Absence of union, either bony or fibrous, between the frag- 
ments. The lateral structures unite strongly enough to permit some 
return of function, but as use progresses and no union exists between 
the fragments they tend to separate. If a fibrous band unites, to- 
gether with the lateral support, it may stretch until considerable 
separation results, but if some of the reserve extensor power of the 
thigh remains intact, function may be quite satisfactory. 

Fibrous Union. — Fibrous union is the rule between the bony fragments 
in most cases not treated by operation and probably in many operated 
cases, but in the latter instance this union is more stable and has 
better backing of the strong lateral ligaments, if approximation is 
performed with complete understanding of the pathology. Fibrous 
union is more common after transverse than after oblique fracture. 

' Bull, de la Soc. Anat. de Paris, 1809, i, 020. 
2 Surg., Gynec, and OVjst., ix, 177. 
4.5 



■()l) 



FRACTURE AND DISLOCATIONS OF THE PATELLA 



The several factors which inhibit coaptation of the fragments favor 
fibrous union, namely, contraction of the extensor muscles, tears in 
the lateral aponeurosis, intra-articular hemorrhage, fibroperiosteal 
interposition, and tilting of the fragments. Bony union does follow 
non-operative treatment, as has been shown by the Roentgen rays 
many times. Morestin^ showed such a specimen. Others after wiring 
operations were reported by Jowers^ and Dreyfus^ in a dissecting-room 
subject. Phelps^ and Chiari, 2 cases, 1 five and 1 seventeen years 




Fig. 491. — Widely separated fragments of the patella complicating other fractures, 

adherent. 

after injury.^ With treatment of today we look for union, often bony, 
in 9 cases out of 10. 

Open fracture is rare, as the statistics show. It is generally due 
to direct violence at the time of trauma, the skin being burst or cut- 
through and the joint opened. Open fractures frequently occur in 
instances of refracture, particularly when the incision is made to lie 



1 Bull, de la Soc. Anat. de Paris, 1896, 5 ser., x, 624. 

2 Lancet, 1905, i, 363. 

3 Bull, et Mem. de la Soc. Anat. de Paris, 1904, vi, 48. 
•* New York Med. Jour., Ixviii, 871. 

^ Prager, Med. Wchnschr., xxx, 35. 



FRACTURES OF THE PATELLA 



707 



across the body of the patella. Imperfectly healed or young scars, 
or adherence between the broken bone and the cutaneous tissues and 
scar cause all to be torn open at once in refracture. ]More will be 
said about this in connection with treatment. 

Symptoms and Diagnosis. — In frank fractures no difficulty is experi- 
enced in finding a displacement. If a fall or direct violence has been 
the cause, the patient finds that his knee is painful, he cannot use it 
to walk well, and he may notice the separated pieces of bone (Fig. 





Fig. 492. — Comminuted patellar 
fracture. There was little difficulty in 
detecting several pieces by palpation. 
Part of the capsular structures arc 
intact in this ca.se because there is not 
a wide separation of fragments. 



Fig. 493. — A fairly wide separation 
of fragments. Complete extension of 
the leg wdth pressure on the pieces 
permitted a coaptation and a result- 
ing crepitus. The fragments could 
also be separately tilted by mani- 
pulation. 



492). Indirect violence with separation of the bone may be accom- 
panied by an audible snap or a feeling of giving way and sharp pain 
in the knee. Some ability to walk may persist, especially if the frag- 
ments are not widely separated {i. e., if the capsular tear is not great), 
for the quadratus muscle retains some extensor power by hyperexer- 
tion via its lateral fibers. In incomplete or non-separated fracture, 
though the pain may be severe, loss of function is not great, and walking 
f»r limping is quite possible. 
A patient lying with the leg extended is unable to raise the heel 



708 FRACTURE AND DISLOCATIONS OF THE PATELLA 

from the bed. Another sign has recently been emphasized by Dreyer^ 
which he considers of importance in determining the type of treatment 
necessary. A case used for iUustration had a separation of 1 cm. 
between fragments, and the man could not extend the leg. Extension 
was applied to the thigh, following which the patient could lift the leg; 
but if the extension were removed the disability appeared at once. 
This test determines in part the laceration of the accessory or even 
the primary extension apparatus of the leg, and Dreyer believes that 
if the power to elevate the leg appears after the extension is applied 
to the thigh, the case should be treated conservatively and not operated 
upon. His opinion has been confirmed by Haeberlin,^ who reports 
a case with bony separation of one and a half fingers' breadth in which 
the application of the Dreyer test demonstrated ability to extend 
the leg. Open operation proved that the muscular apparatus was not 
torn across. 

Swelling of the knee, increasing pain and loss of use follow very 
quickly, as the joint becomes distended with blood and transudate. 
Palpation of the patella with the leg slightly flexed reveals the loss 
of continuity in the bone and the sulcus between its fragments in 
which one can often lay a finger. Sometimes one fragment may be 
small and widely separated. By hyperextending the leg and pressing 
the fragments the operator can rub them together and elicit crepitus. 
This is painful. When the capsular tear has not been complete and 
the bone is not separated, more difficulty in diagnosis exists. If the 
fragments are at all mobile, through the holding of one firmly a false 
point of motion, hinge-like, may be demonstrated (Fig. 493) . Swelling 
of the joint with pain on manipulation of the patella, or a spot of 
intense tenderness on it leads to a probable diagnosis of incomplete 
separation of fragments, and recourse to skiagram should be taken. 
Differentiation lies in hemarthrosis from trauma, in which the patella 
is found intact but possibly floating on the distended joint and not 
painful, or from sprain fracture of the ligamentum patellae. In this 
condition the ligament is pulled away from the patella generally at 
the upper margin, the capsular structures may or may not be damaged. 
The patella may lie at its normal level and show no damage by the 
Roentgen rays, but examination reveals a sulcus just at its upper border 
when the quadriceps has ruptured. 255 cases of rupture of the quad- 
riceps tendon were collected by Walker.^ Of these 140, were below 
the patella and 115 w^ere above. Hawkes^ reports a case of this kind 
in which the tendon and capsule of the joint were both sutured with 
a happy result. Suckett^ records a case in a man aged fifty-seven years, 
who fell W'hile drunk and could not walk or extend the leg. The patella 
was found on a level one and a half inches higher than its fellow. 
On flexion it did not move downward. It was freely movable, and its 

1 Zentralbl. f. Chir., Leipzig, xli, No. 22. 2 ibJd., No. 40. 

' Am. Jour. Med. Sci., 1896, cxxxvii, 638. 

■« Tr. New York Surg. Soc, November 22, 1911. 

5 Ann. of Surg., Ivii, 122. 






FRACTURES OF THE PATELLA 709 

tendon could not be felt at the lower border. Open operation repaired 
the tear in the patellar tendon and capsule. 

Differentiation, in addition to rupture of the ligament, must also 
be made from recent traumatic bursitis. This can be done if it is 
borne in mind that in fracture, even if the separation of fragments 
cannot be demonstrated, the joint becomes distended, the normal 
hollow depressions about the patella are lost, and the patella floats 
on the excess of joint fluid; that is, when the joint is compressed 
laterally the bone when rocked does not impinge on the condyles of 
the femur beneath. In bursitis the swelling is more circumscribed and 
superficial, the patella does not float, and the hollows are not entirely 
obliterated. But one condition may accompany the other. 

Course. — The acute swelling of the knee and its soft parts together 
with the hemarthrosis and distention within the joint follow the frac- 
ture very quickly. If the injury is seen early, further enlargement 
can be prevented by the application of adhesive plaster (after the parts 
are shaved) so fitted as to avoid wrinkles or overlapping of the skin, 
which might cause pressure sores or blisters; or by a snug bandage 
and the use of an ice-bag. If the joint becomes swollen and after 
twenty-four hours threatens to interfere with circulation in the leg, 
its contents can be aspirated aseptically if the hemorrhage is still in 
progress and clots have not formed. After this, it is compressed by 
bandage. Slight displacement and separation may be overcome by 
adhesive bands drawing the fragments together, following which 
union can be obtained, but even in small separations one is never sure 
to what extent the capsule lies between the fragments nor how great 
is the capsular damage. Fibrous union is the result in most cases 
treated thus, as mentioned above, and though after use the fibrous 
band may stretch so that some extension power in the leg is lost, 
walking and ordinary use can be almost normal. Getting up from a 
sitting posture or attempts to raise the leg while lying down a patient 
finds difficult in these cases, and cannot accomplish these actions 
until the leg is a little flexed by the hand, to take up the slack in the 
extensor muscle. Later, this fibrous union may ossify in its whole 
length, or the ossification process extend into the patellar ligament. 
The fibrous union may stretch so much that the function of extension 
is entirely lost and the fragments are widely separated. Following 
this the quadriceps atrophies from disuse. ^Yhen the fragments unite 
by a bony process through any part of their surfaces good function 
follows, unless one fragment is tilted to obstruct free movement or 
the capsular structures are weakened. Small exostoses occasionally 
develop on either surface of the bone. If on the joint side they may 
interfere with motion in the knee. During the course of healing the 
bone seems enlarged, possibly because of its increased blood supply 
or the periosseous infiltration beneath the fibrous covering. After 
union this swelling in most cases subsides but can persist, and by its 
presence interfere with the joint mechanicall}'. Other reasons why 
flexion is limited can be found in the retraction of the capsule or 



710 FRACTURE AND DISLOCATIONS OF THE PATELLA 

fascia lata by the scar, or adhesions within the joint. Loss of the 
power of extension is mainly accounted for by poor union between 
the fragments or by imperfect continuity, if the fibers of the quadri- 
ceps muscle and the lateral tears in the capsule are not repaired. Even 
with impaired power to extend if flexion is full and satisfactory, the 
individual learns new tricks in walking and using the leg, and as he 
trusts it but little his disability is very slight. 

Simultaneous fracture of both patellse while rare is seen. Steinke's 
article with report of 2 cases^ cites 44 cases in the literature, the 
patient's ages varying from fifteen to sixty-five years. 59 per cent, 
were males, 88.6 per cent, were transverse, 6.8 per cent, comminuted, 
2.2 per cent, stellate, and 2.2 per cent. open. One-quarter of these 
in which treatment was given (68 patellae) were not operated upon, 
but all (51 patellae) that were operated on, even 1 in which the patella 
was removed, gave good functional results. 

Refracture. — The patella is the seat of more refractures than any 
other bone in the body, 95 per cent, of the refractures occurring 
through the line of original fracture. According to Corner ,2 after 
operative treatment 69 per cent, of the refractures occur within the 
first year, while in non-operative treatment 86 per cent, of the refrac- 
tures occur after the first year, but the total percentage of refracture, 
disregarding the time factor, is the same after both open and non- 
operative treatment. By means of modern operative treatment with 
little or no splinting following the repair, early passive and active 
motion of the joint and quick restoration to functional use, refrac- 
tures happen less often, as the patient does not have to use crutches 
so long nor is the knee stiff, helpless, and in the way to make him 
clumsy and expose him to the dangers of falls and trips. If the sepa- 
ration is very little, rest in extended posititDn will generally lead to 
union, but if perceptible separation and hemarthrosis are present the 
repair should be done over. I have operated on refracture cases occur- 
ring from five weeks to six months after the original fracture and 
have always been glad I reopened them. One case with kangaroo 
suture and no cast was refractured by the patient falling off a chair 
six weeks after operation. His separation was not quite as great as 
in the first instance, and at the second operation I found a bloody 
joint and much of the kangaroo tendon unabsorbed but torn loose. 
The second operation was done with silver wire and a light plaster 
splint applied to ensure no third occurrence. Final function was 
highly satisfactory, and the patient said the knee felt better after the 
second operation than after the first, a fact which I can explain only 
by the use of the splint after the second operation. 

Refracture occurs in those patients in whom limited flexion is 
caused by malposition of a fragment or by an exostosis. As the patella 
lies over a functionally active joint, joint motion is usually free up to 
a certain point, when it stops abruptly. The patient becomes accus- 

1 Loc. cit. 2 Loc. cit. 



FRACTURES OF THE PATELLA 711 

tomed to this as time passes on, but under extraordinary conditions 
the leg may be hyperflexed beyond this point, causing refracture. 
Attempts at passive motion in the joint beyond a point of safety or 
when pain and contraction of muscles is caused leads to refracture 
by the attendant, but most instances are due to violence, as in the 
original break. If the skin is torn open infection with serious conse- 
quence often results. 

Fracture predisposes to refracture, and yet many reports in the 
literature show that bony union was obtained primarily and refrac- 
ture did not occur through the old site. Remy^ records 2 cases of the 
same patella fractured twice, but not in the original line; Henry, ^ 
1 case eight months after fracture, not in the same site, and Vallas,^ a 
case twenty-six years after the primary break. Murray^ relates an 
interesting accident six months after fracture of the patella with 
healing in which neither the bone nor the callus gave way but the 
ligamentum patellae was torn loose. 

Treatment. — Referring to the pathology of patella fracture one 
recalls the obstacles to bony union which are known to exist. Treat- 
ing the fractures from the mechanical side one recognizes that approxi- 
mation of fragments alone is not all that is needed for union, because 
this approximation may be faulty and fibrous tissue lying between 
surfaces may interfere with union. If great separation exists, the 
problem of drawing the bone together in face of the distended joint 
and the contraction of the powerful quadriceps muscle becomes very 
great, and it is not at all surprising that so many different methods 
(over 90) have been tried and laid aside on account of poor or 
inefficient results. 

Treatment is divided between non-operative and operative care, 
and the arguments for and against open operation are the same in 
the case of this bone as in other bones, with the additional under- 
standing that . the operation is really an arthrotomy on the largest 
joint in the body and on a bone with a poor blood supply, a matter 
discussed at length in the chapter on Operative Treatment. The local 
conditions as given in the preceding paragraph must be carefully 
considered, and if the environment is satisfactory and the separation 
of fragments demand it, open operation is the method of choice. 

Non-operative Treatment. — This method covers a large number 
of maneuvers. Any one which fulfills the following conditions may 
be tried: The fragments of bone must be put in apposition; this must 
be maintained until union has been completed; the continuity of the 
tear in the soft parts, capsule, and synovial membrane should be 
repaired; and the future functional use of the knee must be guarded. 
To attain these ends the attendant must use such means as the cir- 
cumstances, including possibly lack of transportation and his non- 
familiarity with and uncertainty of aseptic technic, permit. Good 
results follow non-operative treatment where there is not much sepa- 
ration of fragments and where the more important capsular struc- 

» Revue de Chir., 1906, xxxiv, 639. 2 Am. Jour. Med. Sci., August, 1899. 

^ Revue de Chir.. 1899, xx, 419. " British Med. Jour., 1898, p. 817. 



712 FRACTURE AND DISLOCATIONS OF THE PATELLA 

tures have not been widely separated or the reserve extensor apparatus 
of the leg is unharmed. 

Distention of the joint from the hemarthrosis calls for first atten- 
tion, and routine treatment as follows can be applied: The leg is 
carefully shaven dry and a well-padded posterior wooden splint is 
made ready which will extend from hip to heel. On this the leg is 
placed and by means of inch-wide adhesive straps applied above and 
below the fragments, each half overlapping the other, some apposition 
is attempted. This requires about eight strips on either side above 
and below, and they can be fixed to the wooden splint for firmness, 
a broader piece being applied directly over the patella area to pre- 
vent tipping of the fragments. In addition to holding the fragments 
steadily in apposition this compression limits further extravasation 
into the joint and hastens absorption. Unusual distention of the 
joint may call for aseptic aspiration by means of a needle thrust in 
laterally at the joint line, but this should be deferred until several 
days' compression and application of ice-bags have been used . If 
enormous distention with great separation is present, the case should 
be put into the operative class at once. Ill-advised or unclean aspira- 
tion may lead to py arthrosis and loss of limb or death. There is never 
an indication for washing out the joint with any solution at the time 
of aspiration. 

A well-applied roller bandage may later take the place of the adhe- 
sive dressing, the fragments should be held together by the fingers 
during its application. Adhesive strips may loosen, or on account of 
skin sweating, need renewal or complete removal. The mole -skin 
zinc oxide plaster or the newer and lighter English adhesive plasters 
are the best. The foot should be elevated slightly, and the patient 
must be kept in bed at least four weeks, no flexion being permitted 
in that time. The thigh and leg may be massaged through the dress- 
ing but not to the detriment of the position of the fragments. After 
this period a light posterior plaster splint or a complete cast is applied, 
and the patient is allowed to get about on crutches for three or four 
weeks. Then the splint is taken off for an hour or more each day, 
massage and active and passive movement of the leg are instituted, 
and after the eight weeks, if union seems satisfactory in the bone, use 
of the limb may be started. 

The greatest care to prevent a fall, overflexions, or traumata against 
the knee is necessary to avoid refracture. The wearing of the plaster 
encasement or splint safeguards against this, but at, the same time 
it should be remembered that by prolonging the immobilization the 
return of function is liable to be hindered. Six months to a year is 
the time required for return of expected function, which is governed 
by the different factors mentioned under pathology. 

Operative Treatment. — Undoubtedly the first bone to be treated 
by open operation for closed fracture was the patella. Severino^ did 
the first open suture on the patella in 1598; the patient died. 

1 Magruder, Jour. Am. Med. Assn., liv, No. 23, p. 1843. 



FRACTURES OF THE PATELLA 713 

There are two operative methods, the subcutaneous and the open. 
The subcutaneous method is now very httle used, and only a brief 
resume need be given. To a\'oid infection and dangerous consequences 
to the hirgest joint in the body, many methods have been devised to 
encircle the fragments by wire or other strong suture subcutaneously 
without entering the joint. Large curved needles which would pass 
around the fragments have been used to carry this suture, holes have 
been drilled subcutaneously into the fragments and wire thus intro- 
duced to hold them together. Hooks, such as Malgaigne's, have been 
offered, whose sharp points entered the skin and tissue above and 
below the fragments and were then brought together by the force 
of a threaded bar which could be screwed up. The methods most 
used were Kocher's, Barker's, Butcher's, and Cecis's. The last- 
named drilled the fragments and inserted his wire in figure-of-eight 
fashion; the three others passed approximating ligatures of some 
metal wire around or over ail fragments. Konig and Kocher, the 
last chief advocates of subcutaneous methods, have now^ given them 
up entirely and are enthusiastically using the open method. 

The reasons for abandoning this method are : 

(1) Asepsis is not assured. 

(2) The fracture practically always involves the joint. 

(3) Since fragments cannot be accurately approximated, union 
may be faulty, with tilting and restricted use of joint. 

(4) Fractured surfaces cannot be freshened and interlying tissues 
removed. 

(5) Capsular tears cannot be repaired. 

(6) Loose fragments of bone cannot be removed from the knee-joint. 
Open Operation. — There is no doubt that the open operation is the 

best treatment when conditions are such that it may be undertaken 
without risk of sepsis. "Conditions," means all conditions governing 
the operative treatment of closed fractures from the hospital technic 
in general to the operator's individual training. Patellar suture by 
any of the methods in vogue is first of all an open arthrotomy, and 
the slight resistance of joints to infection, the destruction and rapid 
spread of suppurative arthritis wdth its immediate danger to the 
patient and the remote consequences from stiffened knee and loss 
of function, must be paramount in consideration. Knowledge of 
these dangers has long existed in surgery, yet so exigent has the 
need of suture approximation of this bone been considered that before 
our present bone aseptic work was developed, this operation was 
cautiously undertaken by many operators who took special pains 
to brush up their aseptic technic for the occasion. At this time the 
operation is done as routine where indicated, and infection is little 
thought of, so surely has the technic advanced. 

To reiterate, open operation permits the correction of the following 
pathological points: 

1 . The tears in the capsular ligaments and the quadriceps femoris 

tCMfloMS. 



714 



FRACTURE AND DISLOCATIONS OF THE PATELLA 



2. The separation of the fragments, removal of interlying prolapsed 
fibrous tissues, and tilting. 

o. Removal of blood and clots from the joint. 

4. Removal of loose bone fragments from the joint. 

5. Avoidance of malunion, adhesions, cicatricial contractions of 
capsular structures, and other mechanical interference with the joint 
action. 

Strong indications for operation exist in simultaneous fracture 
of both patellae, or fracture in a patella with the opposite knee stiffened. 

Contra-indications for open opera- 
tion are also well established and 
may be briefly summarized as fol- 
lows: 

1. In diabetics on account of 
possible interference with wound 
repair, gangrene, low resistance to 
infection, and anesthetic danger. 

2. In any advanced chronic dis- 
eases, as tuberculosis, cardiac and 
renal troubles, or old age. 

3. Subaponeurotic fracture, 
whether transverse or longitudinal, 
without separation. 

4. Very slight separation of frag- 
ments (Fig. 494). 

Many collections of a series of 
operated cases are to be found in 
the literature. Heineck^ collected 
over 1100 cases, Powers, 711 cases,^ 
with 3 deaths due to sepsis ; Phelps,^ 
420 cases, with 3 deaths due to 
sepsis, 1 due to carbolic acid pois- 
oning and 2 to delirium tremens. 
Stimson mentions having done over 
250 operations with one slight 




Fig. 494. — Complete transverse frac- 
ture with slight separation of fragments. 
Operation in this type of case is debat- 
able and depends on the accompanying 
injury of the capsular structures or con- 
tra-indications mentioned. 



superficial infection. Delatour* re- 
ports 101 fractures with 96 opera- 
tions and no deaths. 

Sandrock, from Trendelenburg's 
clinic,^ reviewing the cases treated 
there (Leipzig) from 1895 to 1911, found that there were 116 in all, 
84 of which were operated, the youngest case being sixteen years old 
and the oldest seventy-eight. In this series to obtain relief from a 
large hematoma, the joint was punctured but once, and the convales- 
cence of all cases averaged 41.6 days. Of the 84 operated cases 49 
came back for examination, and it was found that of these 47 had 



^ Loc. cit. 2 Ann. of Surg., xxviii, 67. ^ Loc. cit. 

* Tr. Am. Surg. Assn., New York, 1914. ^ Deutsch. Ztschr. f. Chir., Bd. cxxix. 



FRACTURES OF THE PATELLA 715 

bony union and 2 had fibrous union with a separation of onh' J cm. 
During the seven-^ear period which covers the collection of fracture 
cases made by me at the Cook County Hospital I find that there were 
185 cases, of which 116 were operated. In the year 1907, 11 cases 
operated on were all wired, with one infection; the next year 7 were 
wired and 5 sutured with absorbable material, 1 under each method 
becoming infected, and so on until at the present time but a small 
percentage are wired, kangaroo tendon or absorbable catgut being 
the suture of choice. Out of 116 cases, 7 were infected; 1 reoperated 
case had been done outside the County Hospital, and was infected 
on admission. Xone of these cases suffered death nor badly stiffened 
knees nor prolonged treatment for infection, so that operative treat- 
ment can speak for itself. Alexander,^ in a series of 56 cases had 2 
deaths, 1 in a woman who had a septic abortion ten days after the 
accident and whose leg was amputated three and a half months later, 
death foUowing in two weeks, and the other a man, who died of sepsis 
two months after the patella operation. 

Technic. — Preparation of patient and time of operation. Obser- 
vance of the rules for intact skin and absence of shock, and recognition 
of the contra-indications are prerequisite. There is divided opinion 
among the best of operators as to the time after accident that opera- 
tion should be undertaken. All agree on these points: that shock, 
if present, should have passed, time should be taken to transport the 
patient to the best operative environment possible, and active hem- 
orrhage into the joint should have ceased. Most believe that a 
period of five to ten days should elapse before arthrotomy is done, 
hemorrhage and joint distention should have ceased, absorption be 
in progress, and aseptic inflammatory and protective reaction have 
been instigated in the joint tissues. 

^lurphy- prepares his cases as soon as they are received by inject- 
ing into the knee-joint 15 to 20 c.c. of 2 per cent, formalin-glycerin 
solution of at least twenty-four hours' mixture. This causes an 
infiltration of the synovial membrane and a production of polymor- 
phonuclear leukocytes, which cofferdam the lymph spaces to prepare 
for resistance to infection, hastening and aiding the natural process. 
After seven to ten days. Buck's extension being maintained mean- 
while, the fracture is repaired. Those who operate on these fractures 
at once feel that nothing is to be gained by delay, that their asepsis 
is efficient, and that the convalescence is shortened by early care. 
PersonaUy I prefer to wait. No comparative statistics are to be had, 
as the difference in operators would have to be weighed along with 
the methods. 

The Incision. — ]\Iany incisions for approaching the knee-joint are 
used: one straight, longitudinal or transverse; semilunar concave 
downward; semilunar convexity downward (Trendelenburg or Hahns) ; 
convexity inward; convexity outward; angular incision or H-shaped 

• Ann. of Surg., liii, .508. 2 C'linics. i, 55. 



716 FRACTURE AND DISLOCATIONS OF THE PATELLA 

(see Fi^. 495). Any opening of the skin incurs a possibility of infec- 
tion from the bacteria present in its deeper layers, and most operators, 
weighing this fact, as well as the closure of the wound immediately 
over the deeper repair, prefer the semilunar incision with convexity 
downward from the condyles of the femur nearly to the tibial tubercle. 
This flap is dissected back until the tear in the capsular ligaments and 
the separated fragments are in the field. The longitudinal incision 
fails to expose the field freely, so that repair of the lateral tears is 
difficult, and the scar also is tender to pressure and kneeling. Ross, 
discussing Alexander's paper,^ said that he had seen one case of gan- 
grenous infection in this large incision followed by death. For that 
reason he favored the transverse incision. With this the usual opera- 
tive technic is employed. Sufficient exposure by the incision must 
be given to allow the extreme ends of the capsular tears to be inspected 
and sutured. The fragments are carefully raised and the interlying 
fibrous tissue lifted out from between and cut off, or used for imbri- 
cated suture, as suggested by Andrews. With the leg extended after 
the opening of the joint the fragments in fresh fracture are rarely 
more than three-quarters to an inch apart, and the retraction of the 
quadriceps seldom interferes with their easy apposition. The tear- 



H 



Fig. 495. — Types of incision for opening the knee-joint in repairing fractures. 

ing of the capsule or the distention of the joint by blood causes separa- 
tion. Some operators believe that the joint should be wiped out or 
irrigated to remove these clots. Various solutions have been used, 
plain water, carbolic acid of varying strengths up to 5 per cent., 
bichloride of mercury solution as strong as 1 to 1500, and normal salt 
solution. Lucas-Champonniere ignores asepsis as we believe in it and 
trusts entirely to washing out the joint with carbolic acid solution. 
It appears to be an unnecessary danger to the delicate synovial surface 
with its poor resistance to wash it out with any solution, no matter 
how sure one is of its sterility. Neither is it needful to soak up the 
whole field and wash into the joint juices and bacteria from the cut 
skin surface, nor should the joint surface be abraded by wiping with 
gauze sponges. The operator's simplest procedure consists in his 
picking out with forceps such large clots as present themselves in the 
gaping capsular wound without touching the synovial surface, not 
bothering to attempt to clean out the whole joint. 

Suture Methods and Material. — The different methods practised are : 

(1) Looping the patella (cerclage) with kangaroo-tendon sutures 

(or wire), silver or phosphor bronze, the wire passing through the quad- 

' Loc. cit. 



FRACTURES OF THE PATELLA 



17 



riceps tendon above and below the bone, making circular compres- 
sion to bring the fragments in apposition, after which the wire is cut 
off and pounded lightly into the periosteum. 

(2) Transverse or longitudinal osseous suture by the drilhng of 
holes through each fragment and the use of wire, silk or kangaroo 
tendon. These holes should not penetrate into the joint. If lon- 
gitudinal osseus suture is employed, the drill holes should come out 




Fig. 490. — A fracture of the patella sutured with wire which passed around the bone 
in the longitudinal axis and evidently over the joint surface, a very unsurgical method. 
The wire has broken since operation performed twelve years before the picture was 
taken, and a piece has wandered to the posterior part of the knee-joint. The shadow 
near this wire is the sesamoid in the biceps tendon. Firm union in the patella. The 
patient's opposite knee is a Charcot joint. 



on the fractured surface external to the joint surface. In practice it 
is sometimes difficult to do this and avoid splitting the fragments 
(Fig. 496). 

(3) Simple suture with catgut or kangaroo tendon of the para- 
and peripatellar fibrous tissues (capsular). This method is credited 
to Mickulicz. 

(4) Andrews's method of imbrication closure with kangaroo and 
catgut. 



718 FRACTURE AND DISLOCATIONS OF THE PATELLA 

(5) Complete removal of the patella and the turning down of a 
flap of the quadriceps tendon to fill the defect for attachment into 
the patellar tendon. 

In the 1100 cases collected by Heineck the longitudinal osseous 
suture was employed in 809 instances and the Mickulicz suture in 
240 cases. 

Regardless of the method or material of suture used in the first 
two methods, operators who employ the osseous or encircling suture 
now also use additional absorbable sutures in the tears in the lateral 
ligaments. The wire sutures are falling somewhat into disuse except 
in cases of bad comminution when the encircling method with the 
various wires or kangaroo tendon is an advantage, or in cases of 
refracture opened for a second time where the possibility of a subse- 
quent fracture is to be avoided. An encircling wire suture which does 
not enter the joint seldom gives trouble. Occasionally one leads to 
irritation if the twisted ends are not buried, or one may break and 
have to be removed. 

Murphy uses a twelve-strand, phosphor bronze wire,^ and some- 
times uses two, one a little above the other to avoid the tilting of frag- 
ments. These are knotted and supplemented by catgut in the capsular 
structures. In closing the capsular structures it is advisable to turn 
the flaps up so that the inner surfaces face each other like the 
ectropion of the peritoneum in abdominal closure in order to avoid 
intra- articular adhesions (Fig. 497). 

After-treatment consists of a padded longitudinal splint until the 
patient is out of the anesthetic, when it is removed, or Buck's exten- 
sion with a twenty pound weight, or a permanent plaster or wire splint 
for four weeks, all these to be followed by daily removal and massage 
with passive motion for two weeks and then crutches, massage, and 
active use until function is restored. Dreyer^ advocates the use of 
an extension bandage on the thigh even when operation is performed, 
declaring that this protects against the pulling out of the sutures 
better than casts or splints. Bony union is generally complete in six 
weeks; little active use is to be permitted until the tenth week. If 
circular plaster casts are applied, or the limb is immobilized for a long 
time in the extended position, there is great difficulty in obtaining 
flexion of the knee. Most cases ultimately (six months or more) 
regain almost complete use. Murphy believes that the Buck's exten- 
sion is better than a cast or splint, because it keeps the tibia and femur 
separated and the capsular ligaments elongated and thus gives less 
trouble later in obtaining movement and flexion. 

The Andrews imbrication method offers the following advantages: 
Absorbable material, kangaroo tendon or catgut, is used. The fibrous 
fringe lying between the fragments is used to fold over the opposite 
fragments and is held by two or three mattress stitches which bring 
the bone in firm apposition. They pass up beneath this fringe and 
come out through the periosteal covering of the fragment. An 

i Clinics, i, 843. 2 Lqc. cit. 



FRACTURES OF THE PATELLA 



719 



additional three or four interrupted sutures hold the fringe down to 
the opposite fragment. The capsular structures are then closed 
from one extreme of their tear to the other by a continuous suture of 
catgut. Then the subcutaneous tissues (he uses the transverse incision 
directly over the fracture) are closed by a buried suture of catgut and 
the skin closed by clips. This method gives a layer closure much like 





Fig. 497. — Postoperative anteropos- 
terior \-iew of a fractured patella repaired 
by an encircling silk ligature and catgut 
repair of the ligaments. Apposition does 
not seem to be complete in the roent- 
genogram. Clinically it is complete and 
sufficient to ensure strong union. 



Fig. 498. — Lateral postoperative view 
of fracture of the patella repaired by the 
Andrews's suture method "wdth kangaroo 
tendon. No cast. 



the method of closing the abdomen, uses no wire to cause trouble, 
and if infection occurs in the skin edges, gives it less chance of burrow- 
ing down into the joint through the overlapping folds beneath. The 
after-treatment is as follows: No splint is used. The patient is put 
to bed. The day after operation passive motion of 20 to 30 degrees 
is done. In a week nearly 90 degrees of passive motion and much 



720 FRACTURE AND DISLOCATIONS OF THE PATELLA 

active motion are possible, so that in three or four weeks the injured 
knee has practically a normal range of motion, convalescence is has- 
tened, there is no atrophy of the quadriceps, and no delay for the 
regaining of joint motion (Fig. 498). 

Wyeth^ has suggested a suture of the torn ligaments after washing 
out the joint through a short transverse incision and the use of heavy 
linen subcutaneous sutures one above and one below the patella tied 
outside over a gauze pad. He uses a plaster cast for six weeks, and I 
see no need for the subcutaneous stitches which favor infection and 
the cast which favors joint stiffness. 

In badly comminuted fractures Murphy removes the whole patella 
and uses a flap three-fourths by four and a half inches from the central 




Fig. 499. — Amount of active flexion secured in the third week in a case of patellar 
fracture treated by suture with kangaroo tendon and without the application of a post- 
operative splint. 

part of the quadriceps tendon, which is swung down and sutured to 
the ligamentum patellae. This does away with trauma to the joint 
and the burial of any foreign material. His stand in this matter he 
sustained by exhibition of a case^ of patellar fracture which happened 
in the Civil War (Figs. 499 and 500). Although there was five inches' 
separation between the fragments, the man had a perfect functional 
use of the limb, a fact showing that man can get along without the 
patella. He advises users of this flap method to strengthen patellar 
repair by wiring when operating on fat persons. 

Bone transplantation has also been used in fresh fracture. Vulpius^ 



Jour. Am. Med. Assn., 1915, Ixiv, No. 21, p. 1752. 
Ztschr. f. Orthop. Chir., 1914, Bd. xxxiv, S. 545. 



2 Clinics, i, 326. 



FRACTURES OF THE PATELLA 



721 



reports a case of fresh fracture of the lower third of the patella, the 
lower fragment being badly comminuted. He fashioned a tongue- 
shaped piece from the superior surface of the upper fragment, swung 
it down to cover the deficiency in the lower fragment, and obtained 
prompt healing and good use. Rogers^ records an instance of re- 
fracture three months after the original fracture, in which, in 
addition to the usual suture, he took a graft from the tibia, inserted 
it beneath the periosteum of the patella, and sutured it there. The 
result was excellent, and a roentgenogram nine months afterward 
showed the graft in place, unabsorbed, its under surface blended with 
the anterior surface of the patella and the line of fracture also bony. 
Old fractures, with impaired function, ununited or with attenuated 
fibrous union, require open operation. If the condition is of long 
standing, the difficulties in the way of approximating the fragments 




Fig. 500. — Side view of Fig. 499, showing amount of early active flexion. 

are great. ^lodern early operative treatment has cut down the 
number of these old cases, v>'hich are really confined to those who are 
out of reach of surgical care or who furnish some contra-indication for 
operation at the time of injury. The upper fragment is retracted 
into the subcrural region and often becomes adherent there; the 
lower fragment is pulled down toward the tibia and is encapsulated 
in a fibrous mass. The capsular structures are retracted and fibrous 
and there is atrophy of disuse in the quadriceps muscle. Walking is 
very difficult, the patient may be able to shuffle along on a level sur- 
face but cannot mount stairs or an acclivity. He is in danger of falls 
with injury to this knee-joint or fracture of the opposite patella. Full 
exposure is indicated, the bone fragments are dissected apart, and the 



46 



Anu. of Surg., lix, 70o. 



722 FRACTURE AND DISLOCATIONS OF THE PATELLA 



fibrous union completely removed, the bone surfaces being freshened ' 
by a cutting forceps or saw. If there are cicatricial contractions in , 
the capsular structures, these are also excised and repair done as in 1 
fresh fracture. 

Quenu and Gatellier^ have reviewed these different methods of ■ 
treatment and mention Chaput's subperiosteal resection of the upper ; 
fragment and Lucas-Champonniere's hinge-like reinforcement of the 
fibrous band with metal wires. They report that results since 1893 ' 
have been excellent in 80 per cent, of all cases, good in 17 per cent, j 
and that deaths or failure followed in 3 per cent. The simplest proce- | 
dure should first be attempted — traction on the patella and quadriceps 
tendon aided by V-shaped incision along the edge. The tubercle of 
the tibia may be mobilized completely to secure approximation and 
be reattached. If it is not possible to approximate the fragments, 
excision of the bone can be performed and the flap of quadriceps 
tendon swung down to fill in the gap by attachment to the patellar 
tendon. 

DISLOCATIONS OF THE PATELLA. 

Dislocations of the patella are rare and interesting. Lately they 
are being treated on a common-sense pathological basis. In the records 
of dislocation studied at the Cook County Hospital for seven years 
this sesamoid bone was found dislocated five times. 

To make clear the subject of patellar dislocations it is necessary to 
review briefly the anatomy of the bone and its attachments. As 
stated previously, the bone acts as a protection to the front of the 
knee-joint and in a position of leg extension lies much higher on the 
femoral condyles than is commonly appreciated, articulating with 
the patellar surface of the femur only. This surface consists of a 
median groove or trochlea, which extends in a downward and back- 
ward direction to the intercondyloid fossa of the knee-joint. On the 
side are the convexities of the condyles of the femur which guard 
this groove, the medial convexity being broader and more prominent 
and extending farther up than the lateral. In this groove runs the 
tendon of the quadriceps femoris muscle, and in this tendon the bone 
is developed. The anterior or subcutaneous surface of the patella is 
flat and is covered by a bursa; the quadriceps tendon being firmly 
attached all about its edge except at the lower front, where the patellar 
ligament is fastened. On the posterior surface which lies in contact 
with the femur, are two smooth oval areas which are the articulating 
surfaces, divided by a vertical ridge into two facets, the outer of which' 
is the larger. Below these two facets the bone comes to a sharp point, 
which is rough and does not articulate with the femur behind but 
gives insertion for the ligamentum patellae. On the inner side of the 
knee-joint, aiding the capsular ligament in maintaining the patella 
in position, is the so-called median patella ligament (aileron de la 

1 Revue de Chir., 1913, xlix, 173. 






DISLOCATIOXS OF THE PATELLA 723 

rotiile) a firm, narrow band passing transversely backward on the 
inner side of the joint to the iKotibial fascia. 

Classification. — Acute and Chronic or Recurrent Dislocations. — (1) 
The acute dislocations are divided with reference to the position of 
rest assumed by the patella and are (a) external, the commonest 
variety, which may be complete, incomplete, rotated on edge, or 
reversed; and (6) internal, which are very rare; (c) upward or down- 
ward, which are really due to laceration of the quadriceps insertion 
on the patellar ligament and are not dislocations in the truest sense 
(see Fractm-e of Patella); (d) backward into the joint between the 
femur and tibia locking the knee. 

(2) Chronic or recurrent dislocations can be divided on a pathological 
basis into (a) those following repeated acute dislocations from trauma 
with a minimum of the bone change in the condyles and joint changes; 
(b) those which are congenital and usually bilateral dislocations; and 
(r) those which are recurrent, determined largely by structural varia- 
tions of the knee and relaxed ligaments or by paralytic changes. 

Causes. — The cause of acute dislocations of the patella may be 
external trauma received directly on the bone, forcing it out of its 
place either toward the outer or inner side. Conditions which result 
in this accident may be found by one riding horseback and striking 
the knee against an object in passing, or by one falling on the knee 
with the thigh abducted and violence received on the patella. Mus- 
cidar action also may be a cause, from sudden forcible contractions 
of the quadriceps extensor muscle aided by certain predisposing fac- 
tors. Imperfect action of the muscles produced by cerebral or spinal 
affections or following acute infectious diseases and toxemias, as 
diphtheria, may be primary or contributing causes. 

Congenital and recurrent dislocations are so intermingled with the 
pathology of the joint structures that the two must be considered 
together. In the norm.al leg the weight-bearing line passes from the 
anterosuperior iliac spine through the patella along the tibial crest. 
In knock-knee this line does not pass directly through the structures 
mentioned, and a weight let fall from the anterosuperior iliac 
spine to the ground or a line through this spine and the middle 
of the ankle mortise will fall without the patella and lateral to the 
knee. Consideration of this line is an important point in the pathology, 
for, if the ridge of the external condyle is low and guards poorly the 
groove in which the patella lies, it is not difficult for a sudden contrac- 
tion of the quadriceps tendon to pull the patella out and over this 
edge when the foot and leg are everted. The point of insertion of the 
patellar ligament into the tibia probably plays some part, when this 
is lateral to the middle line and assists in the deviation of the weight- 
bearing line from the centre of the intercondyloid fossa. 1'he extended 
position of the leg with eversion rolls this point of insertion farther 
out, so that, in contraction of the quadriceps and a shortening of the 
muscle from the origin to the tibial tubercle, much force is expended, 
which (aided by the weak resistance of the capsule and median patellar 



724 FRACTURE AND DISLOCATIONS OF THE PATELLA 

ligament) influences the lateral displacement of the patella. The 
condition is further favored by a laxness and superfluity of the tissues 
of the internal lateral ligament and the joint capsule. The position 
of genu valgum of several years' duration has caused an increase in the 
size of the internal condyle and a stretching, with resulting laxness, 
of the capsular structures on the inner side of the joint, involving 
practically the median patellar ligament. Traction of the quadriceps 
muscle, besides causing extension of the leg, is partly resolved into 
another force, which pulls laterally on the patella, causing a constant 
stretching and weakening of the structures on the inner aspect of the 
joint. A sudden severe contraction of this powerful muscle, when the 
foot and leg are everted and the patella rests high up on the femur, 
easily lifts the patella over onto the ridge of the external condyle, 
and as this causes sudden pain the leg is contracted, and the patella, 
dragged down by the patellar ligament, comes to lie outside of the 
ridge of the condyle. If it is pulled clear down and retains its normal 
position without rotating, there is a complete outward dislocation; 
if it rides on the edge of the condylar ridge and does not slip clear 
over laterally, there is an incomplete dislocation. In sliding over 
into a position of complete dislocation the patella may be restrained 
by some intact or shorter fibers of its attachment and be tipped over 
on edge at any angle. Furthermore, in reaching its resting position 
laterally it may be completely rotated on its axis until the posterior 
or joint surface comes to lie anteriorly beneath the skin, so that there 
is a dislocation with complete rotation. 

Pathology. — Damage to the Capsular and Ligamentous Structures.- — 
A displacement of such magnitude cannot be accomplished with- 
out damage to the soft structures which hold the bone, and in 
acute complete dislocations, if they are seen before swelling has 
ensued, the tear in the capsular structures can be palpated through 
the skin. In fact capsular tear is in direct ratio to the completeness 
of the luxation, and when the patella is completely rotated there 
must be capsular tear on both sides of the bone. A case is reported 
by Tenneyi of a young man aged twenty-one years, who was wrestling. 
He felt his knee give out suddenly and noticed the patella standing 
on edge at the outer side of the joint. He pushed the bone into place 
while his friends pulled on the leg. Little reaction followed, but the 
depression became apparent at the inner side of the patella, and an 
opening in the deeper structures about the joint could be plainly felt 
through the skin. Open operation was performed, and a tear Ave 
inches long opening into the joint cavity was found. It was sutured. 

The tears in acute dislocation cause hemorrhage followed by hem- 
arthrosis, ecchymoses about the joint, and in some instances great 
distention. This swelling may disguise the physical findings. If the 
patella is completely rotated so that its posterior aspect comes to lie 
under the skin, the ridge between the facets may be palpated, and 

1 Ann. of Surg., xlviii, 723. 



DISLOCATIOXS OF THE PATELLA 725 

there is practically always a dinipling of the skin over the patella, as 
it is attached by fibrous bands to the anterior surface and these are 
dragged up when the bone is turned about. 

Recurrent dislocations of the patella following acute trauma can 
be explained on the basis of insufficient repair of this capsular tear, 
or a stretching of the cicatricial tissue which fills in the gap after 
repeated injuries to and distention of the joint. It may happen that 
a dislocated patella, um-educed, becomes permanently fixed in its 
new position and function is quite satisfactory. Davis saw such a 
case,^ in which operation was refused on account of the good function. 
If the dislocation has occurred in early childhood and been unreduced, 
or has followed spinal paralysis or diphtheria, the loss of power in the 
extensor muscles favors a continuance of the luxation, and the unop- 
posed flexors gradually draw the legs into position of extreme flexion. 
An instance of bilateral dislocation of this character is recorded by 
Murphy.- The patient, a man, went around in a squatting position, 
and the condition had endured so long that the hamstrings were 
greatly shortened, and it was feared that the sudden full extension 
might rupture or stretch the external popliteal nerve and cause foot- 
drop. 

Dislocations toward the median line are rare, as stated, and as can 
be understood from the anatomy of the parts. They are due to direct 
violence received via the outer edge of the bone driving it inw^ard and 
ruptm-ing the capsule and extensor muscle longitudinally. On account 
of the height of the internal condyle these dislocations tend to reduce 
themselves when the knee is extended. 

Backward luxations, with wedging of the patella between the tibia 
and femur, are due to rotation of the patella on its transverse axis, 
the joint surface being usually turned upward. The joint cannot be 
extended passively. These are always accompanied by great capsular 
and muscular tearing. jNIiller^ says there are but four on record. In 
Szuman's case the external lateral and crucial ligaments were rup- 
tured. 

Symptoms and Signs.— Acute luxation of the patella causes imme- 
diate loss of function with pain in the knee and generally swelling. 
As described in the pathology, the pain of the dislocation often causes 
the leg to flex suddenh', and what may have been but a partial dis- 
location is by that action made complete. Hemorrhage from the torn 
capsule fills the joint unless there is great pressure by the soft parts. 
Inspection reveals the patella out of its normal bed lying external^ to 
the ridge of the external condyle in any of the positions from incom- 
plete to complete dislocation with rotation. The intercondyloid fossa 
can be palpated empty and the smooth edges of the condyles plainly 
felt, as can also the patella be palpated in its new position. If the 
dislocation be seen early, before joint effusion, the tear in the capsule 
or the ridge on the posterior surface of the patella can be felt in cases 

' Ann, of Surg., Ivii, 74. 2 Clinics, iii. 

' Ann. of Surg., Ivii, 737. 



726 FRACTURE AND DISLOCATIONS OF THE PATELLA \ 

of complete revolution, and the diagnosis is aided by the smoothness < 
of the joint surface of the femur and the dimpling of the skin where i 




Fig. 501. — Recurrent outward dislocation of the left patella which is seen lying 
outside the external femoral condyle, the oblique line of the patellar ligament being 
discernible beneath the skin. 




Fig. 502. — Lateral view of Fig. 501. Notice the lateral position of the patella and the 
flattened contour of the knee-joint over the condyles compared to the other knee. 



dragged upon by bands running to the patellar surface (Figs. 501 
and 502). 



DISLOCATIOXS OF THE PATELLA 727 

Diagnosis. — Backward dislocation may be confused with fracture 
of the patella or other injuries to the knee-joint. The secure locking, 
the absence of the patella from its customary position, and the lack 
of patellar fragments are diagnostic and are controlled by roentgeno- 
gram. 

Recurrent cases of outward dislocation are most frequent in chil- 
dren and occur while they are running with attempts to dodge or 
stop. Falls may follow and complicate the injury, or, on the other 
hand, the joint may cease functioning for but a short time because, 
after many recurrences, the individual knows the condition and 
replaces the bone by manipulation. If a child has a knee in which 
complete luxation of the patella frequently happens in running, he 
finds that he cannot stop suddenly, for the patella will be dislocated 
outward completely. The quadriceps extensor contraction acts partly 
as a flexor instead of an extensor, because its force is exerted in a line 
beyond the condyles; hence under these conditions the patient falls 
frequently and yet he has no paralysis, nor is he clumsy in other 
movements. 

Differentiation must also be made between chronic dislocation of 
the patella and fracture or loosening of the semilunar cartilages. 
This can be made through failure to find tenderness over the sites of 
the cartilage on the joint surface, through the noting of the free move- 
ments of the patella laterally, and through the easy reproduction of 
the dislocation of the patella by manipulation. This last the operator 
brings about by having the patient lie on a table, and, slightly hyper- 
extending the leg, bringing the leg and knee near the edge of the table 
without attracting the patient's attention to the maneuver. Then 
the leg is suddenly flexed by being dropped over the table edge, the 
patella at the same time being pushed outward. This causes an acute 
dislocation with the patella outside of the condyle (Figs. 503, 504, 
and 505). 

Treatment. — Acute traumatic dislocations can in most cases be 
reduced easily at the time of their occurrence. Any movement in 
extension with lateral pressure on the bone toward its normal resting 
place may be sufficient.^ The usual instructions for reduction are: 
flex the thigh on the body to relax the quadriceps; fully extend the 
knee to relax the patellar tendon and to allow the patella to take its 
position as high up on the condyles as possible; manipulate the 
patella by pushing it inward to make it ride over the ridge of the 
condyle; grasping the front of the thigh firmly in the hand to aid 
the relaxation, push down the quadriceps. The leg is then flexed and 
the patella assumes a normal position; on account of the capsular 
tears, the hemarthrosis and synovitis, protection from motion of the 
joint is needed, and a posterior splint for a couple of weeks is advis- 
able. Buck's extension is also used to keep the synovial surfaces 
apart, particularly in those joints which have an intense reaction. 

• Whitelock, British Jour. Surg., ii, No. 5, p. 6. 



728 FRACTURE AND DISLOCATIONS OF THE PATELLA 

If there is any tendency to recurrence, a close-fitting bandage should 
be worn over the knee or a brace applied on the inner aspect of the 
leg and thigh to prevent inversion of the knee and eversion of the 
foot, which would favor a renewal. Various pads and knee-braces 
have also been suggested to hold the bone in its proper position. 





Fig. 503. — Recurrent outward dis- 
location of the patella. There was some 
knock-knee present and the patella is 
found riding over the external condyle. 
The patient was nineteen years old, the 
epiphyses in the long bones being still 
unclosed. 



Fig. 504. — Lateral roentgenogram of recur- 
ring outward dislocation of the patella, the 
shadow of which is heavily lined to show its 
turned position lying on the outer side of the 
external condyle. Case treated by osteotomy 
of the femur and subsequent reduction of the 
patella with capsulorrhaphy. 



Old cases, congenital and bilateral, or with a history of many recur- 
rences, can also be treated by braces or pads and maintain some 
function unless contraction of the leg in flexion has occurred and an 
upright position lost. These cases are, however, best treated by 
radical operation. The same may be said of recurrent cases in youths 
with lax knee-joints and marked knock-knee. Firm braces may 
give these patients freedom from recurrence, but the shortest and 
surest treatment is by open operation. 



DISLOCATIOXS OF THE PATELLA 



729 



Operative treatment consists in several methods. If the knock-knee 
is prominent and the dislocated patella can be easily rednced, an 
osteotomy to straighten the femnr jnst above the joint may canse 
complete cnre if firm splinting is applied nntil the bone has healed, 
and a brace or cap is worn afterward for some time. This is a sub- 
cutaneous transverse osteotomy done by a saw, or, through a small 
lateral incision with retraction of the important structures, a large 
chisel can be used in children. 

Acute cases do better and are less apt to recur with an open opera- 
tion (arthrotomy) of the knee. If they are of distinctly traumatic 
origin we know that the capsule and probably the quadriceps muscle 
are torn longitudinally for a varying distance. Open operation with 




Fig. 



>05. — Position of the patella lying on the outer side of the external condyle when 

the leg is flexed. 



suture of these important structures looks toward a control of the 
bleeding, a firm ligamentous union and a shorter convalescence. 
Whitelock^ describes 3 cases. In the first one the capsule was torn 
from the edge of the patella for a distance of four inches. The skin 
and superficial fascia alone protected the joint, as the medial lateral 
ligament of the patella and the vastus internus had been torn asunder. 
Such an operation leaves less scar and does not favor a weak joint 
from relaxed ligaments after the effusion has subsided. 

Acute cases which cannot be reduced by manipulation or which 
show marked capsular tear should be treated by open operation as 



Loo. cit. 



730 FRACTURE AND DISLOCATIONS OF THE PATELLA 

soon as possible. The incision is longitudinal, about four inches in 
length along the inner aspect of the front of the knee-joint. This 
usually exposes the tear in the capsule as soon as the superficial struc- 
tures are opened. The patella if unreduced is lifted over the ridge 
of the external condyle by external manipulation, and the capsular 
ligament is firmly closed throughout its tear by catgut sutures with 
the usual aseptic technic. An additional continuous subcutaneous 
stitch is added above this and the skin is closed with clips or horse 
hair; no drainage is used. A splint with the leg in extension is worn 
at least two weeks, then passive motion in the direction of flexion is 
begun. Weight should not be borne on the leg nor active use mad(i 
of it until all swelling in the joint has subsided, with a minimum of 
four or five weeks from time of operation. 

The operative treatment of congenital, bilateral, or complete recur- 
rent luxation has been slowly improved since Kocher's operation 
described in 1907.^ This operation consisted in carrying the lax part 
of the internal capsule over the patella and suturing it to the outer 
side of the bone. These two ends can be attained with or without 
opening the joint, depending partly on the duration of the condition 
and the adherence of the patella in its dislocated position. Some 
operators prefer to preface the operation on the knee structures by 
osteotomy to correct the knock-knee, if that be present and con- 
sidered one of the causative factors. That seems to be a wise choice; 
illustration of such a case is given (see Fig. 501). The osteotomy- 
should not be too near the lower end of the femur but should be high 
enough to allow complete correction of the knock-knee without the 
making of a sharp angle near the joint and without incurring the 
risk of opening the joint. Grieg^ is a firm advocate of osteotomy, 
as he believes the relaxed capsule has little to do with the tendency 
to luxation, while the knock-knee and its effect on the mechanism of 
extension have a great deal to do with it. The knock-knee corrected 
leads to a gradual change in the structures about the joint and improved 
muscle coordination, looking toward less chance for recurrence. 

In simple cases where the ridge of the external condyle is of fair 
value, repair is made much as in the case of acute dislocation. A 
longitudinal incision down the inner anterior aspect of the joint is 
carefully opened to the fibrous portion of the joint capsule. An open- 
ing is made in this about one-half inch from the patellar edge, and 
this portion of the capsule is then dissected away from the inner or 
synovial layer of the capsule for an inch laterally from the middle 
line toward the inner condyle. This dissection is carried up some 
four inches above the patella level. With heavy catgut stitches the 
median edge of the opened capsule is imbricated beneath the outer 
flap as in taking a reef in the tissue, and the remaining loose portion 
of the outer flap is attached by a continuous stitch well over onto 
the patella area. This overlapping suture runs the whole length 

1 Chirurgische Opera tionslehre, 1907, 5th edition, p, 436. 

2 Edinburgh Med. Jour., July, 1914. 



DISLOCATIOXS OF THE PATELLA 731 

of the dissection, narrows tliQ capsule on the inner side and holds the 
patella firmly in its position; the ni)per end of the incision is further 
strengthened by sutures placed in the vastus internus to narrow it. 

This reefing operation may be supplemented by a plastic on the 
patellar tendon, or the latter can be used alone. GoldtliAvaite/ taking 
cognizance of the lateral insertion of the patellar tendon and its ten- 
dency to favor a pulling force out of the quadriceps in its contraction, 
describes an operation in which he splits the patellar tendon. The 
outer half of its insertion is divided from the tibial tubercle, carried 
behind the inner half by means of burrowing and reinserted on the 
median side of the tibia. Here a small nail or heavy absorbable sutures 
can be used to hold it. The leg is put in extension for several weeks 
to permit the reattacliment of the tendon. 

More recently Robertson'-^ advances an operation for dislocation 
of the patella by the fashioning of a semilunar flap of skin and fascia 
from the medial and posterior surface of the knee back as far as the 
semitendinosus. The base of this flap dissected up crosses the patehar 
area and after the semitendinosus tendon is cut as low down toward 
its insertion as possible, the patellar tendon is split and a short por- 
tion is turned up to be sutured to the cut end of the semitendinosus. 
This gives the pull of the latter tendon to prevent the slipping laterally 
of the patella and the operation is finished by plicating the capsule as 
set forth above. 

Another plastic has been suggested by Whitlock.^ It consists in 
cutting oft' the tendon of the gracilis, swinging it forward and inserting 
it in a split in the patellar ligament. Up to the time of this writing 
I do not know of any other operators having done this, although 
Whitlock first performed this operation in 1909. 

Long-standing or congenital cases require the most elaborate sur- 
gical intervention if the pathology is complicated. If the patient 
gets around with flexed legs as in Murphy's case, the first step must 
be to lengthen the hamstring tendons, either by plastic operation 
or gradual extension by weight and pulley. In these cases some luxa- 
tion of the knee-joint is apt to be present, and the capsule is greatly 
changed from years of contraction and malposition. If the leg can 
be brought into extension by proper means, the problem of the patella 
can then be attempted. Usually these patellae have formed an adven- 
titious bursa beneath them in their new location, the capsular struc- 
tures are firmly bound down about the joint, arid the patella itself 
may be quite immovable. Lack of functional irritation has robbed 
the condylar ridges of the femur of much of their height, especially 
the outer one, which in this class of cases is decidedly weak. Simple 
plication, or imbrication of the capsule will do no good with these 
patients, and the patella must first be freed from its lateral position, 
if necessary by the splitting up of the quadriceps and patellar tendons 
laterally, high above the knee especially. If the patella can then be 

> Boston Med. and Surg. Jour., 1904, cl, 169. 

2 Surg., Gynec. and Obst., April, 1912. ^ Loc. cit. 



732 FRACTURE AND DISLOCATIONS OF THE PATELLA 

slung into i)osition, it is wise to deepen the intercondyloid groove so 
that the external ridge may be a sure protection against recurrence. 
This the operator does by reflecting the joint covering and periosteum 
and cutting down the groove with a large curved chisel, afterward 
covering the denuded bone with the joint tissues and the subquadriceps 
bursa which have been swung back and over. The capsule is then 
plicated, and a happy result expected. Murphy reports a few of these 
operations and gives excellent illustrations of them.^ In some of his 
cases the patellar tendon was also displaced inward and fixed to a 
position corresponding to a normal tubercle of the tibia. 

Backward dislocations of the patella into the knee-joint are prac- 
tically always treated by open operation. Reduction is very difficult 
by manipulation but may be tried by the flexing of the knee further 
and the forcing of the patella out by gravity or shaking. Traction 
on the patellar tendon by means of a hook passed subcutaneously 
may also be tried, but on account of the associated tears in the capsule 
and quadriceps insertion open operation is the best treatment. The 
patellar tendon may require division for the reduction of the bone. 
After it is freed all parts are carefully sutured, or if the nutrition of 
the bone and its surrounding tissues seem to be threatened, it can be 
removed completely and its place filled by a flap of the quadriceps 
turned down from above and sutured to the stump of the patellar 
tendon. 

Prognosis. — Traumatic dislocations promptly reduced and kept 
quiet until the capsule and ligaments have healed give a good prog- 
nosis, except that the joint distention and scar may lead to relaxed 
structures and a tendency to recurrence. If operation is performed 
and careful closure of the tear made, the prognosis is very good. 
Dislocations due to muscular action deserve a more guarded prognosis 
on account of the presence of some of the predisposing anatomical 
causes. 

Manipulative reduction and rest followed by the wearing of an 
elastic knee support or leather cap give a knee which makes walking 
possible, but does not permit full active use of the joint. Operative 
corrections by the methods mentioned promise a good prognosis for 
nearly full use and no recurrence. 

Chronic recurrent dislocations are frequent, and few are cared 
for by the surgeon, because the patient learns to replace them when 
they occur, and the knee, getting accustomed to the trauma of the 
dislocation, has little reaction. Operation offers freedom from recur- 
rence and the wearing of corrective caps and avoids the future weak, 
relaxed and uncertain joint. The congenital and bilateral acquired 
cases are difficult to prognosticate. The operation of deepening the 
intercondyloid groove offers a good prognosis, as all of the cases 
have made excellent recoveries. 

■Clinics, iii, 82 and 151. 



CHAPTER XXV. 
FRACTURE OF THE BONES OF THE LEG. 

TIBIA AND FIBULA. 

The spines of the tibia; the upper end of the tibia or both bones; 
separation of the upper epiphysis of one or both; separation of the 
tibial tubercle; the shaft of one or both bones; supramalleolar, one 
or both; separation of the lower epiphysis; malleolar fractures (Potts); 
lipping fractures of anterior or posterior border of the lower end of 
the tibia. The head of the fibula; shaft of the fibula; separation of 
the lower epiphysis. 

Anatomy. — The tibia develops from three centres, one for each 
extremity, and one for the body or diaphysis (see Fig. 506 for the 
schematic plan). In the diaphysis, ossification begins in the centre 
and extends gradually toward the extremities. For the upper extremity 
a centre first manifests itself about birth and develops with the peculiar 
tongue-like projection for the tubercle, as shown in the figure, joining 
the shaft at twenty years of age. The lower epiphysis appears during 
the second year of life and joins the shaft at eighteen years. The 
tibia is the longest bone in the body next to the femur, and is the 
strongest. Its broad upper end is covered with a thin compacta and 
the body is composed of heavily trussed, cancellous bone, able to 
receive shock and weight. Near the junction of the middle and lower 
thirds the compacta becomes thickest, and the medullary canal is 
well developed; this is the weakest point in the bone from the stand- 
point of fracture, particularly fracture due to torsion and indirect 
violence. 

kThe fibula likewise develops from three centres (Fig. 507). It is 
Imost quadrilateral in shape for the whole length of its shaft; its 
ipper end does not enter into the knee-joint formation, and if it is 
he sole bone broken, fractures in it, except for the twisting breaks 
at the lower extremity, are caused most frequently from direct violence. 
The ligaments of the knee are important. They have been dwelt 
upon at some length in the chapter on Patellar Fracture and Dis- 
locations. In considering the tibia, the most important are the 
patellar, internal and external lateral, the posterior capsular, and the 
two crucial ligaments, anterior and posterior. The internal hiteral 
Hgament passes fn^m the internal condyle of the femur to just below 
the internal tuberosity of the tibia, with branches as described in 
another chapter, and most of the external lateral passes from the 
external condyle of the femur below to the head of the fibula, while 



VA 



FRACTURE OF THE BONES OF THE LEG 



a second smaller portion passes back to join the posterior ligament 
limiting extension and bounding the popliteal surface of the joint. 

Sprain fractures of the knee, like those of any joint, involve these 
ligaments .and their insertions. The ligaments can be torn on the 
bone surfaces or avulsed at their insertion, and the injuries lead to 
much pain and disability, particularly because they are not recognized. 
With the advent of better roentgenographic technic they are more 
quickly discovered and are carefully immobilized to permit small 
loose shells of bone, the cause of irritation and pain, to become 
adherent. Lange^ called attention to these osseous bits. 



Upper extremity 



Appears before or 
shortly after hirth 



Appeals at 2nd 
year 




Joins body 
'about 20th year 



Upper extremity 
Appears about ^^^ Unites about 



4th year 



25th year 



body about 
ISth year 



Appears at 
2nd year 



Unites about 
20th year 



Lower extremity 



Lower extremity 



Fig. 506. — Plan of ossification of the tibia. 
From three centres. (Gray.) 



Fig. 507. - 
of the fibula. 

(Gray.) 



Plan of ossification 
From three centres. 



Fracture of the Tibial Spine (Intercondyloid Eminences). — On the 

head of the tibia are the anticular surfaces, which turn slightly upward 
and are separated by the two tubercles of the tibial spine. Between 
these two tubercles is found a groove which continues in both 
directions and broadens into the intercondyloid fossa. In the wider 
anterior intercondyloid fossa are attached the anterior crucial 
ligament and the anterior edges of the semilunar cartilages. In the 
posterior fossa, which slopes down and backward, the cartilages are 
attached to their respective sides of the spine, while the posterior 
crucial ligament is joined to the rounded surface posteriorly. 

1 Ann. of Surg., xlviii, 117. 



TIBIA AXD FIBULA 735 

From the anterior intercondyloid fossa the anterior crucial hga- 
ment passes backward, upward and outward, and is attached to the 
intercondylar fossa on the inner surface of the external condyle of 
the femur. The posterior crucial ligament extends from the tibial 
surface forward, upward, and inward behind the anterior ligament 
to become attached to the outer part of the anterior portion of the 
internal condyle of the femur. Consequently, as explained by Jones 
and Smith/ the anterior crucial ligament prevents the tibia from for- 
ward displacement on the femur when the knee is fully extended. 
On the other hand, the posterior crucial ligament, in complete flexion 
of the leg on the thigh, becomes tense and prevents the tibia from pos- 
terior displacements. Also because of this attachment both ligaments 
act as a check to inward rotation of the tibia, so that when the knee 
sustains injury and can be abnormally dropped back or pushed for- 
ward from the femur or rotated inward while in an extended position, 
injury to the crucial ligaments can be diagnosed. Knee-joints which 
are subject to a long-standing eftusion or which are the seat of tabetic 
conditions, do not act normally. A fully extended knee will not per- 
mit forward displacement of the tibia provided the anterior crucial 
ligament is intact, and when fully flexed the tibia cannot be displaced 
backward if the posterior ligament is not torn across. 

Roentgenographic study has proved that injuries to the tibial 
spine and crucial ligamentous damage are not so rare as was once 
believed. Godlee's paper in 1888, and Pringle's in 1907, Avere the 
earliest reference to the condition. Pringle found in the knee-joint 
of an amputated leg a loose piece of bone which was separated from 
the tibia and had attached to it the anterior crucial ligament and the 
external semilunar cartilage. This condition he believed was due to 
avulsion of the tibial spine on account of the strain on the ligament 
attached to it. Jones and Smith, however,^ who found 17 cases in three 
years, believe some are caused by traction and others are chips of 
bone not included in the area of attachment of the anterior crucial 
ligament. The original skiagrams of some of these I had the pleasure 
of studying, and I have since seen 4 cases myself (Fig. 508). These 
authors say that a constant sign of fracture of the tibial spine is 
obstruction to full extension of the leg, which obstruction feels like a 
definite bony obstacle in contrast to the softer obstruction from dis- 
placed semilunar cartilages. They divide the injuries into three classes: 

(1) Avulsion of the tibial spine or its internal tubercle. 

(2) Fracture of the external tubercle of the spine. 

(3) Combination of injury to the spine and tuberosity of the tibia. 

(1) It requires great tension on the crucial ligament to cause avul- 
sion of the tibial spine or its internal tubercle. Mayo Robson, Battle 
and Pringle (2) report cases caused by falls on the knee, or a catching 
of tlie leg in wheels. Molence great enough to rupture both crucial 
ligaments would cause dislocation of the knee. Pringle produced 

^ British Surg. Jour,, i, No. 1. ^ Loc. cit. 



'36 



FRACTURE OF THE BONES OF THE LEG 



rupture of the anterior ligament experimentally by fixing the pelvis, 
flexing the knee and abducting the leg with inward rotation. This 
tore the internal lateral ligament also, and with this addition the 
knee becomes flail-like. Kelly, of Liverpool, had a case in which 
both crucial ligaments were ruptured. The skin on the inner side of 
the knee was dimpled and the internal lateral ligament was not torn. 
In all cases of this avulsion the patient cannot fully extend the leg 
and on passive motion feels a bony obstruction. There is no abnormal 




Fig. 508.- — Fracture and avulsion of both tibial spines. There are concomitant 
fractures of the edge of the internal condyle of the femur and the internal tuberosity 
of the tibia. No operation was performed and the leg was useful after immobilization 
in extension. 



mobility such as indicates crucial ligament rupture. The knee must 
be kept at rest for a long time, eight to sixteen weeks, and firm union 
of the tear can be expected. Examination after six weeks' immob- 
ilization shows little abnormal motility, although Pringle asserts, 
that it can be demonstrated if anesthesia is given. 

Rupture of the posterior crucial ligament is rare. As a rule it is 
torn at the femoral attachment. Jones cites a case reported by 
Pagenstecher. 

(2) Fracture of the external tubercle of the tibial spine has no con- 
nection with injury to the crucial ligaments, as this smaller tubercle 
lies without their area of attachment. Experiments on the cadaver 



TIBIA AXD FIBULA 737 

in which the internal hiteral Hgament was divided, demonstrated 
that the inner margin of the external condyle of the femur would 
strike the spine without the division of the posterior ligament, so that 
it is believed that the tip of the external tubercle is nipped off by the 
sharp inner margin of the external condyle. 

(3) Injury to the tibial spine, combined with rupture of the crucial 
ligaments, almost always accompanies dislocation of the knee and 
demands a long immobilization. 

Treatment.^ — Cases of ruptured crucial ligament seen early after 
injury should be immobilized in a plaster dressing or a Thomas splint 
in complete extension for three or four months. In instances of frac- 
ture of the spine of the tibia, the leg should be placed in a position of 
extension by manipulation; then if the tibia cannot be pushed for- 
ward at the knee, and absence of laxity in the joint indicates that the 
crucial ligament is intact, the leg should be immobilized about eight 
weeks. After this it should be given careful passive motion and mas- 
sage and increasing use. 

Cases which are seen late and have not been diagnosed, in which 
the leg cannot be fully extended and there is much disability, can be 
cared for only by operative treatment. The leg is brought over the 
edge of the operating table and let hang as in the operation for the 
removal of loose semilunar cartilage. Incision is made in the mid- 
line on the front of the knee from an inch above the patella to the 
tuberosity of the tibia. The patella is sawed vertically and its ligament 
split longitudinally, after which the fatty tissue beneath is removed 
and the joint is well exposed. The obstructive mass of bone or callus 
which prevents extension is removed, and the joint is closed. In 
some very rare cases with much flexion deformity, arthrodesis or 
arthroplasty with shortening of the bones may be needed. 

Tubercle of the Tibia. — Avulsion or fracture of the tubercle of the 
tibia^ has been called Schlatter's sprain or Osgood-Schlatter disease, and 
has been defined as partial or complete separation of the anterior tubercle 
accompanied or not by tears in the joint capsule or rupture of some of 
the fibers of the quadriceps extensor muscle. The literature contains 
many isolated reports of one or more cases, and doubtless many have 
existed which have not been subjected to roentgenogram or which 
have been totally unrecognized and treated as joint injury or sprains. 
Blake found but two cases in the records of the Boston City Hospital 
and none at all in the Boston Children's Hospital. Eeferring to the 
figure of the ossification of the upper epiphysis of the tibia on page 
734, it is clearly seen that the tongue-like projection which later 
becomes the tuberosity is part of the upper epiphysis. It may, how- 
ever, have a separate centre of ossification. This projection into 
which the patellar tendon is inserted generally becomes com])letely 
ossified by the sixteenth year. If the tubercle is pulled out of place 
by action of the quadriceps before this ossification is complete, the 

1 Blake, Ann. of Surg., Iviii, 207. 
47 



73S FRACTURE OF THE BONES OF THE LEG 

condition is a real avulsion and separation may be incomplete or 
complete with capsular damage as mentioned (Fig. 509). Ihis sepa- 
ration is incomplete because some of the fibers of the quadriceps 
insertion are not inserted into the tubercle. Direct violence also 
may cause the immature tubercle to be displaced, and after ossifica- 
tion it causes more fractures of this point than muscular action. 
Schlatter's sprain in reality is never found after sixteen or seventeen 
years of age in normal children, as it is a separation of the unossihed 
tubercle and is caused by intense muscular effort, as m running or 
lumping. Separation after ossification involves a larger fragment ot 
bone, which may be pulled an inch or more out of place upward or 
turned on its edge. 




Fig 509 -Incomplete separation of the tibial tubercle (Sohlatter's sprainV The 
patellar tendon has j^st started the tubercle from its posrt.on by retraction. Note that 
the epiphyseal lines of the bones are not yet closed. 

The symptoms and signs are well localized. There is inability to 
use the leg, extension being particularly poor and accompanied by 
pain in the region of the tubercle or in the joint. Extension is pos- 
sMe even if the tubercle is completely torn out, as the patellar tendon 

nds occasional bands of insertion to the sides of the t^l^a -ear the 
tubercle The joint may become quickly distended if the capsule 
has been torn o an arthritis has resuhed from any trauma. Exami- 
i: ion demonstrates that the leg can be fully extended passivey 
with little pain; acute tenderness in the tubercle region is felt when 
flexion is performed. Around the tubercle may be a lump, which is 



TIBIA AXD FIBULA 739 

slightly loose, and in moving which crepitus may he found. Corben^ 
reported 2 cases, 1 Avith complete separation, the other just started 
out of place, and Connell- adds 2 cases in seventeen-year-old boys. 
In the first case the tubercle was torn completely off, and there 
was hemarthrosis of the knee, and in the second case the separa- 
tion was caused by jumping on a Aaulting horse. There were no knee 
changes. 

Treatment in the cases with little separation demands that the leg 
be strapped in extension to relax the quadriceps femoris muscle. 
Three or four week's rest is needed with slowly increasing move- 
ments of flexion thereafter. Old cases, undiagnosed, are followed 
by much thickening and tenderness about the tubercle, and Jones^ 
ad\-ises a linear incision with a chisel into the tubercle in the lon- 
gitudinal axis for cure, which is complete in a few weeks. 

Basseta^ believes that some cases are Schlatter's disease, a clinical 
entity which is not connected with traumatic separation of the epiphy- 
sis of the tubercle and describes a case in which the clinical findings 
were manifested first in one leg and then the other with an interval of 
over a year caused by constant irritation, pull of the patellar tendon, 
and exaggerated ossification. There is probably a parosteal thickening, 
but if skiagrams can be made in the very early stages, undoubtedly 
some movement of this epiphysis out of place could be determined. 

If the tubercle is completel}' torn off from the tibia or the upper 
epiphysis is started out of place in much of its length, open operation 
for replacement and holding by nail or wire is indicated (Fig. 510). 
Gibson^ records a case nailed extracapsularly with an excellent result, 
and he refers to Erlmann, who had 2 cases, 1 operated and 1 treated 
by pressure bandage, and to Tilton, who had 2 cases, 1 wired and the 
other sutured in place by chromic gut with good results. Other 
instances are reported by Fowler*^ and Osgood.^ 

Fractures of the Upper End of the Tibia Alone or the Tibia and 
Fibula Together.— These fractures are caused by direct or indirect 
violence, the former accounting for many of the severely comminuted 
fractures of both bones which extend into the knee-joint. Such vio- 
lence may come from dhect blows as from a hammer, falls from a 
height, and in one severe case (Fig. 511) has come from a jump from 
the engine cab b}' an engineer to avoid certain collision, followed by his 
striking with his full weight below one knee against the steel rail of 
the opposite track. Indirect violence is exerted through a twisting 
of the leg with the thigh fixed, the leg being carried most frequently 

' Practitioner, April, 1914. 2 Practitioner, July, 1914, p. 146. 

' Proc. Roy. Med. Soc, December, 1910. ^ Arch, di Orthop., 1913, xxx, 305. 

' Ann. of Surg., liii, 431. 

' Internat. Jour. Surg., February, 1914, xxvii. No. 2. 

■ Boston Med. and Surg. .Jour., 1903, cxlii, No. 5, p. 114; Overlook, Connecticut State 
Med. Jour., 1907, p. 288; Keyser, Sajou.s Annual, 1888, ii, 267; Ware, Ann. of Surg., 
November, 1904. p. 739; Winslow, Ann. of Surg., February, 1905; Poland, Traumatic 
Separation of Epiphy.sis, 1901; Mueller, Beitr. z. klin. fhir., November, 1887 j) 257- 
Landsl>erg, Centralbl. f. Chir., September 28, 1889. 



740 FRACTURE OF THE BONES OF THE LEG 

ill abduction. The line of fracture assumes any direction Strictly 
transverse fractures are rare; oblique are common and usually nivolve 
the knee-ioint or separate one tuberosity from the head and mush- 
room it down on to the shaft. If both tuberosities are crushed off, 
thev separate near the middle of the joint. This fracture may mvolye 
the tibial spine and likewise be jammed down by impaction onto 
the shaft (see illustrative cases, Figs. 512 and 513). 




YiG 510. — A more complete type of separation 
of the tibial tubercle which has been lifted nearly 
half an inch out of place on the shaft. Planes 
of separation into the epiphyseal line and the 
body of the tibia are shown. There is also a 
small free body within the joint, probably a 
piece of avulsed bone. 



Fig. 511. — Comminuted fracture 
of the upper end of the leg bones 
from direct violence received in a 
fall on a steel rail. 



Direct violence acts in different ways, depending on the position 
of the leg. If there is a fall, or a blow strikes the tibia directly, this 
bone alone mav be broken as described above; or if the violence is 
received by the patient while standing and supporting his weight, 
the line of force divides itself into two parts. One acts m a longitudmal 
direction, to resist which the upper end of the tibia was made so broad 
and of cancellous bone capable of taking up jars, and the other by 



TIBIA AXD FIBULA 



'41 



lateral pressure against the upper end of the bone which is supporting 
weight. 

If the longitudinal force from the body weight is in preponderance, 
the bone splits. One or other tuberosity may come off, depending 
on which tuberosity receives the greater force, and the shaft is driven 
up between with accompanying injury to the fibula (Figs. 514 and 
515). Should lateral pressure be great enough because of torsion or 
a giving of the leg or its retention against a solid object, with the 




Fig. .512. — Fracture of the tibial head 
by direct violence. The fibula is not broken. 
Plane of fracture passes in two directions, 
one at right angles extending into the joint 
between the intercondvloid eminences. 




Fig. 513. — Linear plane of fracture 
of the upper end of the tibia opening 
into the knee-joint. 



foot Still bearing weight, the fibular head breaks off, the u})per end 
of the tibia breaks across (Figs. 516 and 517), and there is more lateral 
displacement and not so much penetration of the shaft fragment 
into the upper fragment (Fig. 518). These same forces may cause 
fracture of the condyles of the femur and leave the tibia intact. Lon- 
gitudinal fracture is uncommon, probably because the lines of the 
bone lamellte spread laterally in the upper part of the bone and do 
not favor a direct splitting of the whole diaphysis, and the interi)()si- 
tion of the epiphyseal area favors an end of the separation. A case 



742 



FRACTURE OF THE BONES OF THE LEG 



illustrating longitudinal fracture took its origin from low down in 
the shaft and passed upward for nearly the whole length of the bone. 
Displacement is in accordance with the direction of fracture. Even 
transverse fractures with little separation show the tendency to impac- 
tion or mushrooming mentioned above. The body weight favors 




Fig. 514. — Fracture of the tibial head by 
indirect violence received in a fall. The 
fibula is not broken. The external tuberosity 
is split off and the joint surface comminuted. 
View looking at the knee from behind. 



Fig. 515. — Fracture of the external 
tuberosity with great displacement and 
involvement of the fibula, the head of 
which is mushroomed down onto the 
shaft. The knee appears in subluxation 
outward. 



this jamming in of the fragments, and the abduction or rotative 
factor of the trauma aid it further. When one or both tuberosities are 
broken off or split, they tend to have lateral displacement with much 
broadening of the upper end of the bone. If fracture of the fibular 
head accompanies this, it may cause extensive widening of the bones 
below the knee. The popliteal vessels and tibial arteries are in this 



TIBIA AXD FIBULA 



^43 



field and subject to dangerous injury, which may end in gangrene 
and amputation. The joint always suffers an effusion or a hem- 
arthrosis, the latter surely if the fracture extends into it. This joint 
swelling becomes the most prominent feature of the injury, masks 
the findings of the bone fracture, and may seriously impede circula- 
tion by its size. If pressure threatens to cause a bursting of the skin 
or to interfere with circulation, aseptic puncture can be done and 
aspiration of the joint performed. 





Fig. 516. — Fracture of both leg bones 
just below the knee by direct compres- 
sional violence. Oblique fracture. Body 
weight ha.s impacted the fragments 
slightly. 



Fig. 517. — Oblique fracture of both 
leg bones caused by direct violence with 
some impaction caused by the body 
weight. 



Diagnosis. — Diagnosis is based on the history, the loss of function, 
pain and tenderness, reaction and broadening of the joint, and change 
of axis f)r shortening of the leg. Careful palpation along the edge of 
the tibia discovers irregularity and pain at the site of fracture. If 
the fracture is not deeply imi)acted, crepitus and abnormal motility 
are present. IVansverse fracture, high up near the joint, or epiphyseal 
separation must be distinguished from dislocations of the knee. The 
great rigidity, the pain on any attempt at motion, and the palpation 



744 



FRACTURE OF THE BONES OF THE LEG 



of the rounded tuberosities in dislocation out of their normal position, 
are helps. 

Course and Prognosis. — The swelling of the knee or the interference 
with circulation may become matters of prime importance. Ice- 
bags should be applied at once, the joint put at rest in comfortable 
support until much of the reaction has subsided. If the fracture is 
impacted and the joint is not opened into and complete reduction is 
not obtained early, bony union proceeds with broadening below the 

knee, a slight shortening of the leg, 
and a slight axial deviation. Final 
results are fair but take from six 
months to a year to culminate; they 
may be aided by a lift on the sole 
of the shoe or other corrective 
methods. If the knee-joint is in- 
volved, or great effusion into it exists, 
the prognosis is always grave. A 
tuberosity broken off and displaced 
by a fracture plane into the joint 
unites in malposition, callus wanders 
into the joint, the long immobiliza- 
tion required leads to thickening 
and restriction of the synovial sur- 
face and the formation of adhesions. 
The final result may be complete 
ankylosis of the knee-joint with 
much broadening, the under surface 
of the patella becoming adherent to 
the femur. Suppuration of the 
joint is possible. The long relaxa- 
tion of the ligaments from effusion 
and immobilization leads to a weak- 
ened joint in those joints not stiff- 
ened as a result of the trauma, and 
final function is much impaired. If 
active massage and motion treat- 
ment is persisted in after pain has 
left the knee, cases which seem to 
offer poor outlook often give a final 
result that is surprisingly good. Ten months or a year is not an 
unusually long time to wait to obtain good use. 

Treatment. — Before the reaction to the trauma of fracture has 
thoroughly set in, reduction can be accomplished to a satisfactory 
degree in many cases by extension and counter-extension on leg and 
thigh with local pressure over the displaced fragments. Anesthesia 
should be employed in all cases. If the swelling and knee distention 
have already taken place before the surgeon sees the case, these require 
first care, as it is impossible to be sure of manipulative reduction in 




Fig. 518. — Fracture of both bones 
at the upper end with lateral and 
anteroposterior displacement. Vio- 
lence acting in a transverse plane did 
not cause an opening into the knee- 
joint. Some of the fracture plane 
passes through the closed epiphyseal 
line. 



TIBIA AND FIBULA 745 

their presence. It seems the best rule under these circumstances 
to elevate the foot of the bed and apply extension from below the 
knee with a weight of fifteen pounds, the line of traction being one 
which favors correct alignment of the axis of the whole limb. It 
must be recalled that in men the axes of the tibit^ are vertical to the 
ground surface, while in women there is slight bowing on account 
of broader pelves and more widely separated femora. Excellent 
results can be obtained by the early application of this traction, if 
it is steadily maintained and if sufficient weight is used to overcome 
the muscular action and thus allow the unlocking and correct align- 
ment of the fragments. This also separates the synovial surfaces 
of the joints and tends to obviate intra-articular adhesions and further 
keeps the joint ligaments stretched, so that on attempts to resume 
use they have not so contracted as to interfere with function. In 
some impacted cases the mechanical extension gives relatively easy 
and immediate reduction, which is held by a split plaster cast or a 
wide posterior moulded splint. 

Each case must be treated to meet the findings of the fracture 
with the following thoughts in mind : 

(1) Avoidance of change in the tibial axis. 

(2) Avoidance of adhesions in, and ankylosis of, the joint. 

(3) The prevention of shortening, if possible. 

A cast or splint which extends from the foot well up onto the thigh 
prevents axial displacements and disappointments after the permanent 
dressing is removed. This should be applied while the leg is in exten- 
sion and under traction. The continuous extension by the Buck 
apparatus for a couple of weeks pulls many fractures into the joint 
to a good position and after that time a plaster encasement onto the 
thigh can replace it. After the third week the patient can become 
ambulatory, with crutches and a lift under the well foot to prevent 
the possibility of weight-bearing on the injured leg. If the joint 
is concerned, the rule following fracture into joints should be adhered 
to and the immobilization made at least 50 per cent, longer; in these 
cases immobilization should be employed eight weeks and then passive 
motion and massage can be begun gradually and never to a painful 
extent. After a year results are final in well-cared-for cases. 

llarely, on account of wide separation of the tuberosities or com- 
minuted involvement of the joint, it seems wise to open these fractures 
and nail the fragments closely together. This is a dangerous pro- 
ceeding to undertake while the hematoma is fresh and extends into 
the joint, for there is little resistance to infection, and if it is once 
started, the whole joint is soon involved. x\fter time for subsidence 
and absorption of this blood is allowed, callus formation has proceeded 
and frequentl\' little can be gained by attempts at nailing. Early 
manipulative reduction with steady heavy traction is by far the best 
method of treatment. 

Open fractures of this character are very dangerous. Every effort 
is made to aft'ord proper drainage and no chance for infection. The 



746 FRACTURE OF THE BONES OF THE LEG 

leg is enclosed in copious dressings after thorough treatment with 
iodine and dressed with sterile gloves each time. If infection follows, 
counter-openings, and gutta-percha drains should be inserted from 
the dependent portion of the joint with avoidance of important 
structures. The early use of autogenous vaccines obtained from 
cultures of the pus, frequently gives prompt subsidence of the infec- 
tion in the bone and joint and should be invoked in every case. 

Separation of the Upper Epiphysis. — This injury is rare, and there 
are but few cases of the uncomplicated displacement on record. Poland 
collected 24 cases. This epiphysis unites with the shaft as late as 
the twenty-fourth year, and as early as the twentieth, and includes, 
as indicated in the diagram (Fig. 506), the whole articular surface 
of the tibia, the tuberosities and the tubercle, which sometimes has 
a separate centre of ossification arising about the eleventh year and 
persisting a year or two before fusing with the rest of the epiphysis. 
The cause is usually a violent twisting or wrenching of the leg and 
produces practically never more than a partial displacement. Most 
of the recorded cases are of movement forward of the epiphysis on 
the shaft, although the displacement is sometimes combined with 
lateral movement outward. Hutchinson^ says that the separation 
at this epiphysis is rare, because the insertion of the internal lateral 
ligament, the ligamentum patellae, and the semimembranosis tendon 
cover both the epiphysis and part of the diaphysis, and these liga- 
ments are powerful connecting retainers of the epiphysis to the shaft. 

Treatment. — Treatment consists in early complete reduction under 
anesthesia. The knee is flexed to relax the hamstring tendons, and 
then the tibia is pulled forward into position while counter-extension 
is made on the thigh above. As the separation is through the soft 
epiphyseal tissues, they hold themselves when reduced and do not 
tend to be displaced again. Results after reduction are excellent, and 
no trace of the fracture remains in a few months. If complete reduc- 
tion is not accomplished, there is sharp angular deformity at the 
site of separation, and in the course of time the leg adapts itself to 
the change in the tibial axis enough to establish good function. After 
reduction no weight should be borne on the leg for from four to eight 
weeks; a moulded splint or a circular cast should be applied. After 
this is removed the leg should not be used until all tenderness has 
gone, and the patient should be particularly' careful about climbing 
stairs to avoid stumbling or the pulling out of the tubercle that has 
been involved in the separation. ^ 

Fractures of the Shaft in its Length, Including Supramalleolar 
Fractures. — The two causes of these fractures are direct and indirect 
violence. The former may be applied at any point in the shaft and 
results in fracture of one or both bones,. Bardenheuer has said that 
when a force is applied against the long axis of a bone it resolves 

1 British Med. Jour., July 16, 1887. 

2 Walton, Fractures and Separated Epiphysis. 



TIBIA AXD FIBULA 



747 



itself into two components, one on the convex and one on the concave 
side of the bone. The tibia or both bone fractures of the leg furnish 
the best example in their shafts of this mechanism and also of the 
mechanism of torsion or torsion combined with some flexion. Several 
distinct types can be attributed to direct violence, as illustrated in 
Fi^s. 519 and 520. 





Fig. .519. — Transverse fracture of 
Ujth leg bones caused by direct com- 
pressional violence. The broken out 
wedge-shaped piece is comminuted. 



Fig. 520. — Transverse fracture of the 
tibial shaft with some separation of the 
lower epiphysis, caused by direct violence. 
Fibula unbroken. 



These show that in complete fractures from direct violence or 
flexion fracture, the transverse separation is found only when the 
force is applied at right angles to the long axis of the bone. The 
lines of fracture diverge from the beginning of the bone separation 
on the convex side of the curve in flexion. They tend to run toward 
the concave side of the flexion in such a manner that a triangular 
or wedge-shaped piece of Iwne is burst out with its base toward the 



748 



FRACTURE OF THE BONES OF THE LEG 



concave side of the flexion. This broken-out piece may be com- 
minuted. If the force of flexion or direct violence acts more slowly 
or less vigorously, only one of these divergent lines or fissures may 
become complete, so that an oblique fracture results (Figs. 521 and 
522). Pure flexion fracture of the tibia is not the common finding. 
Such fracture is more often located in the lower third of the shaft 
where the cortex is thickened and the medullary cavity is best defined. 
Although it is true that pure flexion fracture requires violence applied 
at a right angle to avoid the influence of torsion, this type may be 
produced indirectly as well as directly. If two forces are applied to 





Fig. 521. — Oblique fracture of the 
tiljia with comminution of the small 
fragment. Fibula unharmed. Cause, 
direct violence. 



Fig. 522. — Oblique fracture of both 
bones, healed with deformity. Note the 
mass of callus between fragment ends 
where the periosteum was stripped up. 



the leg on opposite sides and at a distance from each other, a flexion 
fracture results indirectly, or, should these opposing forces be on the 
same level, comminution of the shaft results, with longitudinal fis- 
sures, and if one force is just above the other, the result is transverse 
fracture with lateral displacement, called a shearing fracture (see 
chapter on Etiology and Mechanism). 

Whether the fibula is also fractured depends largely on its elasticity. 
Fractures of the tibial shaft alone are more common in children, 
because in them the fibula is more elastic. In adults and the old 
because of greater rigidity, if the torsion continues the smaller bone 



TIBIA AXD FIBULA 



749 



is generally broken at a higher level with a line similar to that of the 
tibial fracture. Should flexion enter into the mechanism, the fibula 
is likely to sustain a flexion fracture. 

Torsion fractures of the tibia or of both bones result from torsional 
violence at either end of the Ijmb, that is, with the foot and ankle 
fixed, the torsion coming from the trunk above as it is swung around, 
or the limb above is fixed and the twisting force is applied at the lower 
end. Spiral fractures are more common in the leg than any other 
part of the body. In young individuals, 
on account of a higher coefficiency of elas- 
ticity in the bones, the spirals of shaft 
fractures are steeper and longer (Fig. 
523). It seems also true that, because 
external rotation of the mobile peripheral 
part of the leg is more common than 
internal rotation arising from the swing- 
ing of the trunk, spiral fractures of the 
right leg are left-handed, that is, the 
curve passes down as a staircase with a 
left-handed turn, and spiral fractures of 
the left leg are right-handed. The ex- 
ceptions to this rule are those cases 
caused by internal rotation of the limb 
from the trunk swinging above. Conse- 
quently we expect the same type of frac- 
ture, whether the foot or lower leg is 
rotated violently outward on the fixed 
limb above, or whether the trunk rotates 
the proximal portion of the limb inward 
while the foot is fixed. In true oblique 
fracture caused by flexion the pointed 
ends of the fragments lie on opposite 
sides of the bone, as illustrated in the 
diagram modified from v. Bruns, but in 
torsion spiral fracture of the tibia the sharp 
ends are usually on the same side (the pos- 
terior surface) of the shaft, connected by 
a longitudinal line which runs down the 
anterior aspect of the shaft (Fig. 524). 

Shaft fractures of the leg bones assume all the varieties of displace- 
ment. They are transverse, buckling, oblique, with and without 
overriding and rotation, comminuted, and in a large percentage 
involve both bones. Oblique fractures from compression when the 
fragments are completely separated are constantly rotated through 
a varying angle (Fig. 525). These fractures may be opened from 
within by the sharp points of bone, or in direct violence are frequently 
opened at the time of injury by the trauma. The nutrient artery 
may be broken off at its point of entrance or other arteries and nerves 
in the leg injured, but these complications are quite rare. 




Fig. 52.3. — Spiral fracture of 
the shaft in a young adult. Note 
the steep angle of the plane of 
separation. 



750 



FRACTURE OF THE BONES OF THE LEG 



In the pathology of the healing, complications arise as follows: 
Adherence of tendons and muscles to the callus, shortening of the leg 
from incomplete reduction, change in the axis of the distal portion 
of the leg leading to an improper weight-bearing line and its complica- 




FiG. 524. — Spiral fracture of the 
shaft in a forty-year-old man. The 
spiral is rather abrupt. Callus of repair 
shown. 



Fig. 525. — Long spiral fracture of both leg 
bones seen from the side. There is some over- 
riding and anteroposterior displacement with 
angulation in the leg. This type may easily 
puncture the skin covering. 



tions (Fig. 526). Excess callus is rare in the leg. Thickening of the 
leg with edema of the distal portion and interference with circulation 
arise from incomplete reduction. Delayed union, fibrous union, or 
non-union are more common in the leg than in any other part of the 



TIBIA AND FIBULA 



751 



body, in the author's experience, and yet with careful attempts at 
reduction these results do not happen in more than 3 per cent, of all 
cases. 

Symptoms and Signs.— The position of these two bones beneath the 
superficial tissues makes diagnosis easy. Pain, change in the leg 
axis, swelling, and loss of function are constant findings. Crepitus 
is very frequently found, and the deformity is usually so apparent 
to the eye that measurements of the leg are not needed to verify 
overriding or shortening (Figs. 527 and 528). By passing the fingers 
down the crest of the tibia the surgeon can find the point of bony 
separation, or in incomplete fracture can locate the point of constant 
recurring tenderness. The same procedure 
along the shaft of the fibula gives positive 
findings in both bone fractures. Incomplete 
fractures, or the extent of radiating cracks, of 
triangular fragments, and of torsion fractures 
are shown clearly by roentgenogram. 

Treatment. — The spare covering of these 
two bones by the leg tissues, the strength of 
the muscles covering them, and the diflficulty 
of maintaining prolonged extension make good 
results very difficult to obtain in treatment. 
It appears that no ideal treatment has yet 
been devised for oblique or torsion fractures 
involving the shaft of the tibia or both bones 
of the leg. Incomplete or fissure fractures, 
fractures of one bone with little displacement, 
transverse or shearing fractures are amenable 
to satisfactory treatment. Manipulation with 
extension under anesthesia suffices to give good 
reduction, and treatment should aim to fulfill 
these conditions previously mentioned: 

(1) It should overcome axial deformity in 
the leg. 

(2) Shortening should be avoided. 

(3) Complications, such as delayed union, 

adherence of tendons, chronic swelling of the distal portion and loss 
of function should be guarded against. 

In all t^-pes, except the oblique and torsion fractures, early proper 
reduction meets these requirements. If needed to overcome displace- 
ment the mechanical extension can be used and a circular cast or 
moulded splint applied, immobilizing both knee and ankle. Routine 
treatment consists in the placing of the leg in a comfortably padded 
fracture box or blanket splint, the application of ice for a few days 
until the swelling is gone, and then reduction. Kanavel^ has sug- 
gested a combined board and blanket splint which is easily made and 




Fig. 526. — Healing 
fracture of the tibia. De- 
formity with overriding 
and callus development. 



Surg., Gynec. and Obst., June, 190G. 



752 



FRACTURE OF THE BONES OF THE LEG 



( 



ends of the longitudinal board 



by means of the pieee nailed aeross the 
(see Figs. 529 and '^'M)), holds the leg steadily up from sagging into 
the bed. All circular casts should be cut open and rebandaged at the 
time of application. Four to six weeks will give good union. After 




Fig. 527. — A common type of shaft fracture 
of yDOth bones. The fibula is broken on a 
higher level and a piece is split off the tibia 
so that there is lateral and angular displace- 
ment. Compression combined with torsion 
was the cause. 



Fig. 528. — Compression fracture of 
both bones, the fibula breaking after 
the tibia. Note the callus and the 
opportunity for ugly deformity if 
better reduction is not made. 



three weeks the leg can be removed daily from the cast for massage 
and passive motion. 

Tenotomy of the calcaneus tendon has been suggested as a means of 
overcoming the contraction of the soleus and gastrocnemius muscles. 



TIBIA AXD FIBULA 



■53 



This I have done in a few cases and been able to secure easier redac- 
tion, but the cases did not turn out weh otherwise, and it is a debatable 
question whether the leg ever regains full power when this tendon is 
cut. Wharton^ considers this measure good practice in irreducible 
cases. G. G. Davis, discussing this point, recalls the anatomical 



Si* 



Fig. 529. — Kanavel's board and blanket splint for leg fractures. Boards approximated 
to the leg which lies in the blanket swing. 

and mechanical facts of the leg muscles division into four groups: 
first, the anterior set, composed of the anterior tibial, the extensor 
hallucis and the extensor communis digitorum; second, the posterior 
set, the tibialis posticus, the flexors of the toes and great toe; third, 




I'^IG. 5.30. — Blanket iinri !)r;ard splint with cro8s-i)iecc nailed 011 end. lieiiilorcing bandage.-; 
ahfjut the splint are not shown in the |)icture. (Courtesy oi Dr. Kanavel.) 

the three abductors, the peronei which do not influence flexion and 
extension to any great extent; and histly the calf muscles, the gastroc- 
nemius, soleus and plantaris, which really have nothing to oppose 



' Ann. of .Surg., lii, 27(). 



48 



754 



FRACTURE OF THE BONES OF THE LEG 



them. If the calcaneus tendon is cut, we should look for a muscle 
balance in the leg, but, as mentioned, the tenotomy may do per- 
manent harm to the calf muscles. Davis suggests that to get rid of 
their action the leg should be placed in Pott's position, i. e., flexed 
on its outside, following which reduction may be much easier (Figs. 
531 and 532). 

Mechanical extension with force of 100 to 150 pounds applied by 
the portable apparatus, or while the patient is on the fracture table. 




Fig. 531. — A good result of 
manipulative reduction and 
plaster encasement. The 
weight-bearing Hne of the tibia 
is nearly correct. 



Fig. 532. — Lateral view of Fig. 531. There is prac- 
tically no anteroposterior angular deformity nor much 
shortening. 



gives a happy result, if it is maintained until the circular cast has 
hardened. This must be applied over copious padding, and if the 
primary fracture reaction has subsided in the leg the cast may not 
have to be cut open; but the toes must be watched for coldness and 
lack of capillary circulation, and if pain or numbness appear, the cast 
is split open at once. I have had no pressure sores or untoward results 
in cases treated in the last four years, but do frequently find one- 
fourth to three-eighths inch shortening. A few cases treated by this 



TIBIA AND FIBULA 



755 



method are reported by Peckliam.^ Other means of obtaining length 
and lessening deformity consist in applying the plaster first to the 
foot and leg above, leaving the site of fractnre open. Extension is 
then applied over the foot portion to lengthen the leg, the fragments 
are manipulated into place and held there while additional plaster 
is applied outside of the two parts already on the leg to make one 
continuous cast. This is open to the objection that one cannot be 
sure of the effect of the pressure on the casted foot. The site of frac- 
ture tends to swell and become edematous and mav interfere with 




Fig. 533. — Swenson's adjustable 
apparatus for continuous leg extension. 



Fig. 534. — Swenson's extension apparatus 
applied to Buck's extension. 



distal circulation. If it is necessary to split the cast, the plaster 
frequently cracks apart and the extension force is lost. 

Oblique and torsion fractures may be happily reduced by means 
of extension, but the slightest relaxation of the extending force permits 
a sliding past of the oblique surfaces so that the deformity recurs 
(Figs. 533 and 534). This is difficult to avoid by any means. The 
use of mechanical extension, and the application of a plaster encase- 
ment which is allowed to harden before the extension is loosened may 



Jour. Am. Med. Assn., Ixiv, Xo. 4, p. 308. 



75G 



FRACTURE OF THE BONES OF THE LEG 



be successful. A Thomas splint with continuous traction or an exten- 
sion applied by adhesive from a point below the fracture, may be 
useful, but though good axial replacement may be thus obtained, 
results in nine-tenths of the cases manifest some shortening or loss 
of function arising from tendon interference or chronic swelling. No 
weight should be borne on oblique fractures until the callus is very 
firm, ten to twelve weeks, and six to eight months is not too much 
disability after severe grades of this injury. 





Fig. 535. — Plated reduction of spiral 
fracture of the tibia, applied on lateral 
surface. 



Fig. 536. — Plated reduction of an 
oblique fracture of the tibia. Note that 
the plate is not set on the anterior sur- 
face of the bone just beneath the in- 
cision. 



Operative Treatment. — The statement concerning ideal treatment 
and results made in the preceding paragraph finds application here. 
The best reductions and maintenance are obtained by the Lane plate. 
The scant covering of the leg, the difficulty of approximating and 
tightly closing the skin after the operation of plating favor infections 
in these opened legs. Plates should be large and with sufficient screws 
to hold the leg firmly, and it is the best practice to apply them on the 
lateral aspect of the bone w^here they can be covered by the thick 
muscles, as the tibialis anticus, and not lie immediately beneath the 
incision and its closure (Figs. 535, 536, 537, and 538). If infection is 
late and of mild character, or the operator chooses to ignore it alto- 



TIBIA AXD FIBULA 



757 



getlier in his treatment, preferring to get good approximation and 
remove his plate at the earhest opportunity after union, this treat- 
ment may be the best of all, though two operations are needed and 
the possibility of chronic osteomyelitis exists. I have seen many 





Fig. 537. — End-result in a plated 
fracture of the tibia. The plate was not 
long enough and pulled out the com- 
pacta of the lower fragment, permit- 
ting some slipping displacement. 
Good callus nevertheless. 



Fig. 538. — An example of inefficient 
plating in fracture of both leg bones. The 
plate was too short and probably there 
was insufficient external support applied 
for too short a period so that the plate had 
to bear the stress of weight-bearing before 
bony union. 



cases of disability of one or two years following infection about Lane 
plates applied on the tibia, especially in the lower third of the bone. 
The time of removal in most of these cases had not been delayed. 
Kecently I resected one-third of the tibial shaft subperiosteally to 
remove necrotic and ununited bone one year after [)lating, the plate 



758 



FRACTURE OF THE BONES OF THE LEG 



having been taken out two months after insertion, fragments of bone,, 
some containing screw holes, having been discharged in the meantime. 
One case which was of interest followed a gunshot fracture of the 
tibia. Some weeks after the original injury a surgeon opened the leg 
and put it in good alignment by the application of an eight-screw 
plate. A good recovery with an aseptic wound and good function 
resulted. Thirteen months later the patient came into my hands 
with some soreness in the shin and a small sinus developing. The 
plate was a source of irritation, infection had started about it, and 
1 had to remove it. In doing so I observed that the bone at the 

lower end had grown around the plate 
firmly. It had to be chiseled loose. 
Prompt recovery from infection and 
disability resulted. Another case oper- 
ated in the same week had been plated 
some three months before with apparent 
aseptic result, but had little function 
on account of the short time since frac- 
ture. The man came to me with a sinus 
similar to that of the preceding case. 
This plate was removed and the wound 
left open for drainage, but the infection 
in this tibia, although apparently no 
more extensive than in the first case 
mentioned, took nearly nine months 
to quiet down and close. These two 
examples were in men in different voca- 
tions and with different personal care 
and resistance. The one who carried 
the plate nearly a year was a well- 
nourished business man of excellent 
habits who had no focal infection that 
could be discovered; the other was a 
railroad switchman with many unhy- 
gienic habits and infected teeth, was 
not well nourished nor of high resist- 
ance. Such factors as these should be 
considered in selecting cases for internal 
splints, in the leg particularly. When infection first manifests itself 
the plate should be removed and the bone not disturbed. It is wise 
to prepare an autogenous vaccine from cultures taken at the time of 
operation. 

Souttar^ suggested a right angle plate built like a T steel beam with 
one arm lacking, which appears L-shaped on cross section. I have 
used a slightly-modified type of the plates on lower third tibia frac- 
tures and like them very much (Fig. 539). The fragments are brought 




Fig. 539. — Operative reduction 
of a fracture of both bones near the 
ankle by a modified steel Souttar 
plate. The skin clips show the 
length of the incision. Only one 
angle of the plate shows, the other, 
containing the screws is set at a 
right angle on the inner surface of 
the tibia. 



Ann. of Surg., November, 1913. 



TIBIA AND FIBULA 759 

into apposition by open operation, and by means of a circular saw a 
slot is cut into them, crossing the line of fracture in a longitudinal 
direction. Into this slot the right-angled wing of the plate is slipped 
and lightly pounded until the other wing, which I have had made 
with a slight curve, fits down flatly onto the outer surface of the 
shaft. This portion has screw holes in it, and when the screws are 
inserted the plate is found clamped down very firmly to both frag- 
ments, the slight curve mentioned allowing the outer tip to bite down 
against the bone and give great security. The wing buried in the 
bone tissue prevents lateral movement, the wing fastened along the 
shaft surface prevents motion in the anteroposterior plane as would 
a Lane plate, and the whole gives perfect and very firm apposition. 

^Yires are frequently used to hold the fragments together. Silver 
or phosphor-bronze wires inserted through holes made in the cortex 
have little value in holding these fragments together unless the frac- 
ture is distinctly transverse. If it can be reduced, even by open 
operation, simple reduction without the wires often holds, and it is 
better to omit the foreign body. A more favorable method is to 
wrap firmly several strands of phosphor-bronze wires around spiral 
fragments to hold them together. Strauss^ has suggested the use of 
a filigree of woven strands of catgut applied around, the bone to hold 
it in position. 

Other valuable methods are those using external clamps or rods 
which penetrate into the fragments and bring them into line. Free- 
man^ advocated their use through small skin incisions, fixation clamps 
or sterilized plaster of Paris holding the rods in position of good bone 
alignment (see chapter on Operative Treatment). Sabotte's and 
Parkhill's clamps are essentially the same, but Sabotte has given up 
their use except in cases of infected open fractures. 

The nail extension in accordance with Steinmann's method is also 
used in the leg. Lyle^ presented 3 cases so treated, 2 of which were of 
both bones of the leg. One was an open comminuted fracture which 
was treated by the nail extension for nineteen days and then put 
in a plaster encasement; the other was an infected comminuted open 
fracture treated by this extension for forty-seven days. Woodward"^ 
is enthusiastic over this method and finds that the anatomical results 
are all that could be desired (see general chapter on Treatment for 
Hackenbruck's method). 

Comments on Steinmanns Nail Extension. — The disadvantages 
belonging to this method may be enumerated as follows: 

Infection in the nail tract, necrosis of the skin of the heel, and 
osteomyelitis or other sequences. By adhering to a strict asepsis in 
operating, using a steel nail with the end pointed, and plastering 
over the wounds with collodion dressings the operator can avoid 
much trouble. In practice I use a smooth-polished, steel rod, which 
I obtain in two-foot sections. A piece sufficiently long is cut off and 

' Surg., Gynec. and Obst., xix, Xo. 3, p. 410. ^ Ann. of Surg., liv, .381. 

^ Ann. of Surg., Ix, 397. < Practitioner, London, 1914, xrii, .UiO. 



760 



FRACTURE OF THE BONES OF THE LEG 



Olio end bluntly pointed with a file. The point for insertion is selected 
on the outer side of the heel about the middle of the bone, the skin 




Fig. 540. — Wire loop around nail passed through the calcaneus. Rope attached for 

extension. 

drawn down a bit and an incision about three-eighths of an inch long 
made with a sharp scalpel down to the bone. This opening is retracted 




Fig. 541. — Same foot as preceding figure. 

and the nail driven through the calcaneus exactly parallel to the sole 
of the foot. As the nail point arrives at the inner side of the foot a 



TIBIA AND FIBULA 



•61 



small incision over the oncoming point is made by the assistant, while 
the operator drives the nail on through, leaving an equal projection 
on either side. The collodion dressings are at once applied, followed 
by sterile dressings and bandage. Outside of this dressing the two 
nail ends appear. 

Heavy copper or picture wire is used as a loop o\er the ends to har- 
ness the extension (see Figs. 540 and 541). To prevent this from 
slipping off, a shorter loop is applied to hold the two ends together 
across the sole like a stirrup. Sufficient weight, at least fifteen pounds 
in an aduh, must be applied to overcome shortening. The leg is bol- 




FiG. .542. — Patient's foot w-ith nail exten- 
sion and weight applied. 




Fig. 54.3.— a spiral fracture of 
both bones of the leg treated by nail 
extension. Picture taken the day 
leg was removed from the cast 
which had been applied when the 
nail was removed twenty-one days 
after insertion. 



stered on a padded board held in position by narrow sand-bags laterally, 
and frequent inspection is made that the attendant may be assured 
that everything is in position and that the weight is pulhng. The 
foot of the bed should be elevated (see Figs. 542 and 543). 

Overcorrection can rarely occur. The formation of a fistula is 
generally caused by too long maintenance of the extension, errors in 
technic of insertion, or of asepsis of withdrawal. The smooth rod gives 
little difficultv. The cases I have treated by this method gave no 



762 FRACTURE OF THE BONES OF THE LEG 

rise in tcin])erature. Spiegel discusses 18 cases, 14 of which were 
for leg fractures. Fistuhe developed 5 times in 8 cases, necrosis (bed- 
sore) was present in 8 cases, requiring an average of nineteen days to 
heal and furnishing a chance for infection. Swelhng in the ankle- 
joint may result during or after the extension, just as after mechanical 
extension and the application of plaster encasements, but ankle stiff- 
ness caused by nail extension in the foot yields to treatment more 
readily than stiffness caused by plaster immobilization. In Spiegel's 
cases the nail broke three times, I believe because it was of too small 
size. Other complications, as the nail cutting through the bone, 
and healing of the fracture with deformity or knock-knee, arise from 
technical errors in the size of the nail and insufficient postoperative 
care of the maintenance of position. 

Other modifications have been made Jor this extension by Nove- 
Josserand, and Rendu and Michel. ^ They have adopted a sort of 
plaster breeches, using the pelvis and sound thigh which are attached 
to the head of the bed by straps for counter-extension. This method 
is applicable to children who cannot be restrained and are not old 
enough to realize the importance of holding the leg in position. 

Waegner^ made a report on 70 cases of fracture treated by nail exten- 
sion. He contrasts his cases with Korber's 70 cases reported in 1911.^ 
Twenty-four of Korber's cases suppurated, 9 lightly; 12 had fistulse. 
Waegner's 70 cases were treated with no infection at all. In 11 of 
them he obtained a thick drop of secretion after the nail was removed. 
Cultures made of this secretion showed Staphylococcus albus 4 times, 
sarcinse alba 5 times, and no culture twice. There were no complica- 
tions, as the patients were all reactionless and 59 of them had per- 
fectly dry wounds. He emphasizes the necessity of considering this 
method a surgical one, to be performed with surgical asepsis, and in 
surgical surroundings, especially in connection with the care of foot 
and the removal of the nail. 

Gelinsky^ uses a wire extension from the heel, but he does not bore 
through the calcaneus. He prefers to put the wire through the inser- 
tion of the tendo Achilles, avoiding vessels and nerves. The extension 
is brought out over a small splint on the sole of the foot which is 
attached by adhesive plaster. An extension line to the weight is also 
applied to the forefoot, so that each part of the foot bears one-half 
of the force, and the line of traction corresponds to the leg axis. This 
application, he believes, is the only perfect and safe method of applying 
extension to the foot in malleolar and supramalleolar fractures (see 
description under Calcaneus Fractures). 

Very satisfactory results are obtained by the intramedullary splint 
of autogenous bone. This should be firm enough in the medullary 
cavity to hold the fragments in position, and is rather difficult to insert 

1 Disser. Berlin, 1913, Accidents in Nail Extension. ^j^^vue d'Orthop., 1913, v, 487. 

3 Verhandl. d. deutsch. Gesselsch. f. Chir., Berlin, 1914, xliii, i Teil, 201-3. 

'' Miinch. med. Wchnschr. 

6 Zentralbl. f. Chir., Leipzig, xli, No. 34; also Zentralbl. f. Chir., Leipzig, 1913, p. 812. 



TIBIA AND FIBULA 



763 



when the tibia alone is broken, unless the interosseous ligament is 
cut through for a short distance to allow the fragments to be turned 
out of the wound (Fig. 544). Good alignment can always be obtained 
by this method, though some shortening may persist as the fragments 
tend to slip past each other on account of their obliquity. Ivory screws 
or nails, wire nails and metal screws are useful in selected cases, depend- 
ing largely on the operator's skill and custom (Figs. 545, 546, and 547). 





Fig. 544. — Fracture of both bones 
treated by an intramedullary peg. The 
alignment is good. Skin clips on skin 
edge. 



Fig. 545. — Anteroposterior view of the 
preceding figure. A long peg is necessary 
to give stability to this repair. 



Open fractures arising from the causative violence or from fragment 
penetration are treated in accordance with the instructions for those 
cases in the general chapter on Treatment. Bryant^ advocates the 
immediate application of a plaster encasement about these legs after 
the limb is shaved and the wound protected with gutta-percha. The 
cast is then cut open over the wound and the edges of the plaster are 



Tr. Am. Surg. Assn., 1912. xxx. 



■()4 • 



FRACTURE OF THE BONES OF THE LEG 



])r()toc'to(l c'()ini)letoly by gutta-percha to prevent soiling and to 
allow drainage and dressing. The limb is swung up in elastic suspen- 
sion by rubber bands. The same result is accomplished by the use of 
an interrupted cast bound together by U-shaped bands of metal 
over the open wound (see Fig. 548). 





Fig. 546. — Repair of spiral fracture 
of the shaft by intramedullary peg. This 
postoperative picture shows a slight over- 
riding, but the clinical result was perfect. 



Fig. 547. — Repair of spiral frac- 
ture by intramedullary bone splint. 
Note that some overriding persists. 



The complications of delayed and non-union are frequent in the shaft 
of these bones, especially in the lower part. The easiest method of 
treatment is for the surgeon to put on a i&rm plaster encasement which 
will allow the patient to become ambulatory and to bear a little weight 
on the foot as he gets about with crutches. If this fails, the ends of 
the fragments may be drilled aseptically or a regular open operation 



TIBIA AXD FIBULA 



7G5 



performed. Intramedullary autogenous bone splinting is the best 
treatment, and must be supplemented by freshening of the fragment 
ends. An inlav graft has also been advocated bv some operators 
(Fig. 549). ^ ^ • ^ 




Fig. 548. — Interrupted cast for open fracture of the leg. Firmness assured by bent iron 
bands laid into the plaster. Whole foot swung up to facilitate dressing. 

Henderson^ suggests the cutting of a long, bevelled slot running into 
both fragments. From one side a longer piece is cut; that is taken 
out and inserted into the equivalent slot of the shorter fragment 
and bridges across the site of fracture, while the shorter fragment 
removed from the slot fills in the remaining deficiency (Fig. 550). 
Albee- also uses this method. It works admirably in simple cases of 
non-union with little displacement; in fresher fractures the inlay has 
less holding power and needs wires or accessory nails for maintaining 
the position of the splint and fragments. Lyle^ records a case of both 





Fig. .549. — Diagrammatic representation of Gallies bone wedging. The wedge-sliapcd 
pieces are reversed after removal, the operator taking pains to be sure that one piece 
is longer than the other so that it will overlap the fracture plane when transposed. 

l)one fracture of the lower third of the leg ununited after three and a 
half months, which was then treated by Bier's method. He injected 
20 to oO c.c. of the patient's own blood around the })()nes every six 



• Ann. of Surg., lix, 4^0. 
'Ann. of Surg., Ivii, 2H4, 



^ Aim. Jour. Surg., 1914. 



766 



FRACTURE OF THE BONES OF THE LEG 



days, using sterile albolene to prevent clotting, and after the eighth 
injection obtained union. It is difficult to decide whether the time 




' 




Fig. 550. — Albee's method of inlay bone graft. Small bone dowels hold the inlay in 

place. 

element, the irritation of the needle, the blood, or the albolene was 
the main factor in producing union, but these elements coupled with 
patience are well worth trial (Figs. 551, 552, 553, 554, and 555). 






Fig. 551 Fig. 552 Fig. 553 

Fig. 551. — Ununited fracture of the tibia of two years' standing. The leg has a false 

point of motion in its middle and was held in flexion from muscular contraction. 
Fig. 552. — Side view of Fig. 551, showing the angularity of the leg. 
Fig. 553. — Repair of ununited fracture of the tibia by an inlay graft after fastening 

the ends of fragments. A small nail in upper end of graft to hold it in place. 



Prognosis. — The prognosis of leg fractures involving the shaft is 
in most cases hopeful. Some shortening is present in 70 per cent, of 



TIBIA AXD FIBULA 



"67 



cases; this is compensated for by an additional lift or two on the sole 
of the shoe. Edema of the leg, venous stasis below the fracture, and 





Fig. 554. — Inlay graft in un- 
united fracture. 



Fig. bob. — End-result of this ununited fracture. 
There was an inch shortening of the leg easily 
overcome by a lift on the sole. 




Fig. 556. — Backward displacement in epiphy.seal separation of the lower end of the 
iibia. This type of fracture is easily mistaken for posterior dislocation of the tibiotarsal 
joint. 



pain may be present for many weeks, l^'unctioii usually iuipr()\es 
rapidly after use is attempted, provided the callus is firm and the 



768 



FRACTURE OF THE BONES OF THE LEG 



aliiiiimcnt is good. The outlook for younger individuals is brighter 
tlian for those in later life. 

Separation of the Lower Epiphysis. — This happens more frequently 
than separation of the upper epiphysis and is caused by twists of the 
foot and other indirect violence, as in falls, or by forced dorsal or 
plantar flexion of the foot with a continuation of the force in a lateral 
or shearing manner. As the cause always contains some torsion force, 
it is a common finding to have a spiral split running into the shaft of 
the bone. This is not a long plane of separation and is usually of the 
outer surface, i. e., next to the fibula, as most of the torsions are in 
that direction. When the epiphysis is displaced backward (as in Fig. 
556) the posterior surface of the diaphysis may be split off. Cotton, 
in 1908, found that the records of the Massachusetts General Hos- 





FiG. 557. — Epiphyseal separation of 
both leg bones at the lower end accom- 
panied by a second fracture of the 
fibula a little higher. 



Fig. 558. — Anteroposterior view of Fig. 
557. Note the lateral displacement in 
addition to the anteroposterior shown in 
the first view. 



pital contained 15 cases of this separation, only 5 of which involved 
the epiphysis alone; in the other 10 the diaphysis was also concerned 
(Figs. 557, 558, 559, and 560). The ages of these cases were from seven 
to seventeen years. Poland states that these injuries occur usually 
between the ages of nine and seventeen years, that 1 out of 28 cases 
was under nine years of age, namely, six years (Figs. 561 and 562). 

The question of interference with growth is an important one, 
as it is of all epiphyseal separations, particularly so in this region 
which is so intimately concerned with the function of locomotion. 
Coolidge^ expresses the opinion that 1 out of 8 or 10 of these epiphyseal 
separations result in no growth, and cites his own case as an example. 
When six years old he fell off a fence, and the foot was found to be 



Boston Med. and Surg. Jour., clix, No. 15, p. 470. 



TIBIA AXD FIBULA 



'69 



loose and flabby but without open wound. The case was treated as 
a fracture with a good result. A year later there began to appear on 
the outer side of the ankle a bunch which grew steadily larger and on 
account of which a brace was worn for four years which made pressure 
on this mass, with no result except the pain it caused. The deformity 
increased up to sixteen years of age, when it stopped with the leg 
one and a half inches short, impaired in its ankle motions, and pos- 




FiG. 559. — Epiphyseal sepa- 
ration of both bones at the lower 
end with a plane of separation 
entering the ankle-joint and a 
fracture of the fibula higher. 
One concludes that the joint 
complication and the fibular 
fracture were secondary- and 

lused by longitudinal pressure 

Iter the epiphysis was WTenched 

It of place. 




Fig. 560. — Reduction of displacement shown in 
Fig. 559. Note the position of adduction in which 
the foot is held by the plaster during repair. 



sessing a tendency to roll outward. The explanation lay in tlie fact 
that the lower epiphysis of the tibia had ceased to grow after separa- 
tion, but the fibula had continued to extend and has shot down below 
the tibia, shoving the whole foot inward so that the line of body weight 
extended down through the fifth metatarsal bone, and the line of the 
ankle mortise was very oblique. Scudcler discussed C'oolidge's case 
and gave as his opinion that interference with growth after separation 
49 



'0 



FRACTURE OF THE BONES OF THE LEG 



ill the epiphysis is not often seen, because the epiphysis has an inde- 
pendent blood supply and the thick, softer periosteum is seldom all 
torn. For growth to be interfered with, circulation must be restricted 
with destruction or great displacement of the cartilage, which becomes 
involved in the callus. If this happens while the upper end of the 
bone grows more rapidly, if the injury occurs in a young child, a 
symmetrical growth will follow. 

Diagnosis. — The diagnosis rests with the finding of a loose, displaced 
ankle in a child of susceptible age. The points of the malleoli bear a 
normal relation to each other and are not painful. There is great swell- 
ing and ecchymosis, with crepitus usually very soft or absent. If the 




Fig. 56] . — Transverse fracture just 
above the lower epiphysis which is 
clinically difficult to differentiate. The 
presence of distinct crepitus and the 
age of the patient are important 
points. Ip this patient the unclosed 
epiphyses did not yield. 




Fig. 562. — Another type of supra- 
malleolar fracture not involving the 
epiphyses. The malleoli are intact and 
the talus lies normally in the ankle 
mortise. 



fibula is also broken it is at a higher level, and differentiation from 
dislocation of the ankle hangs on the age of the patient and the normal 
relation between the malleoli and foot bones. 

Treatment.^ — The treatment is to reduce the deformity at once. 
This can usually be easily done under anesthesia and the leg put in 
a suitable cast or splint, as suggested for supramalleolar or lower 
shaft fractures. Rarely reduction might- fail on account of a fragment 
from the diaphysis. If it does, open operation with reduction must 
be performed at the earliest opportunity. Old cases with union in 
the deformed position wiiich have never been reduced should be 
treated by open operation, the surgeon cutting through the callus and 
replacing without internal splints. 



TIBIA AXD FIBULA 



1 



Malleolar Fractures, Internal or External Malleolus Alone or 
Together. Pott's Fracture. Lipping Fractures of the Posterior or 
Anterior Articular Surface of the Tibia. — These conditions must 
all be dealt with under one general heading, as the causes are common 
factors, the results varying with the slightest degree of difference in 
the amount of torsion and the bones of different individauls. For- 
merly all fractures involving the ankle-joint were called Pott's frac- 
tures, but the refinement of diagnosis with modern methods has 
changed our ideas somewhat. In another place I have recorded a 
studv of 208 cases of ankle or Pott's fractures.^ 




Inte rtarsal art icidat ioiis 



Tarsometatarsal 
articulaiions 



Fig. 563. — Right talocrural intertarsal and tarsometatarsal articulations. 

aspect. (Gray.) 



Medial 



These ankle injuries are very common, and my investigation at the 
Cook County Hospital, Chicago, showed that they constituted 15 
per cent, of all the fractures discharged from the institution in the 
year 1913. The caw.^e is indirect violence and torsional strain accom- 
panied by some compressive force from the body weight delivered 
through the ankle mortise. This strain is generally received on account 
of a twist of the foot, by a fall or slip off a small height, as a curb- 
stone, or a fall from a height onto the foot in position of abduction 
or adduction. The torsion is communicated to the bones of the leg 
from the foot by the pressure upward, or upward and lateral of the 
astragalus in its mortise, aided by the pull and resistance of the ankle 



speed, Surg., Gynec. and Obst., July, 1914, p. 73. 



772 FRACTURE OF THE BONES OF THE LEG 

ligaments. For the sake of refreshing one's anatomical knowledge or 
conception of this important point, refer to Figs. 563 and 564, illus- 
trating the various ligaments, and Fig. 565, which portrays exactly 
the shape and extent of the mortise which locks in the astragalus. 

Pathology. — When abduction and eversion of the foot are the 
cause of the fracture, the astragalus is pushed outward, and the fibula 
tends to break at a point above the termination of the tibiofibular 
ligament in a transverse or oblique line from compressive force. Coin- 
cidently the internal lateral ligament either ruptures or, holding its 
insertion into the tibia, pulls off the internal malleolus squarely near 
its lower end (Fig. 566) . If this eversion continues strongly, the lower 




Tibiofibular syndesmosis 



Ankle-joint 

y 

Intertarsal articulations 
Tarsometatarsal 
articulations 



Fig. 564. 



-Right talocrural intertarsal and tarsometatarsal articulations, 
aspect. (Gray.) 



Lateral 



fibular fragment may be separated a little from the tibia by tearing 
of the tibiofibular ligament, and the internal malleolus is correspond- 
ingly dragged outward by the internal lateral ligament, and comes 
to lie under the joint surface (see Fig. 567). Some torsion is present 
in all these cases. It is controlled and does not manifest itself patho- 
logically because of the shape of the ankle mortise, with its strong 
posterior lip and the very strong tibiofibular ligament. If the torsion 
is a more predominating factor in conjunction with the eversion, we 
obtain the spiral fractures of the external malleolus, as this point 
projects lower down than the internal malleolus and meets with most 
of the force in external torsion and eversion. These spirals, in a 
quickly acting force, are above the lower end of the tibiofibular liga- 



TIBIA AND FIBULA 






ment which by a sHght elasticity liolds while the rigid bone gives, but 
in slower-acting force with more eversion or compressive violence from 
the body weight, the extreme end of the external malleolus is frac- 
tured and splintered up in a spiral manner. As a rule there is not 
much damage to the internal malleolus and the internal lateral liga- 
ment in this mechanism (see Fig. 568). Sometimes in eversion, in 
addition to fibular fracture, the tibiofibular ligament is torn, a con- 
dition permitting wide separation between the bone ends and possibly 
accompanied by a shell of bone pulled out from the tibia (see Figs. 
569 and 570). 



Interosseo^is ligament of tibio- 
fibular syndesmosis 



Medial tmiUeolu^ 

Deltoid liaament — *7^B^^BK^^Jf3«^7.w-/'^/VcKr<« ^ i * L^fiAi'.:{i\ 

^V>" Lateral malleoli 

Tibialis posterior ,,^ ^wwrnavvv-^^v \ -■ "'•t.-..^-^(''vm///^jv 

Calcaneofibular ligament 
~ — Interosseous talocalcaneal 
ligament 

Peronceus brevis 

Peronceus longus 
Abductor digiti quinti 



Flexor digitorum longu.^- 

Flexor hallucis longus 

led. plantar nerve and vessel^ 

Quadratus playiioe 

AbdtLctor halluci- 

L<it. plantar nerve and vessch 
Flexor digitorum hrevi 




Fig. 565. — Coronal section through right talocrural and talocalcaneal joints. 

True malleolar fracture must take place at a point below the inser- 
tion of the inferior tibiofibular ligament and leads to impaired motion, 
Vjecause the joint is opened and a small amount of callus may enter 
into the articular surface. A small splinter of bone may become com- 
pletely detached and enter into the joint as a loose body. 

If the healing process results in an angular union of the distal frag- 
ment or this callus formation, joint interference results, or chronic 
arthritis with painful and restricted motion ensues. For this the 
only remedy is open operation to remove the offending piece of bone 
completely, or to loosen it and reattach it at the normal angle to the 



774 



FRACTURE OF THE BONES OF THE LEG 



fibula. The removal gives relief from pain, and the strong lateral 
ligament reforms, if sufficiently long rest is given the ankle. 

Sprains of the ankle are a result of this mechanism when it stops 
short of breaking the bone. It is possible to find the lateral ligaments 
severely torn or even between the bones ligament ruptured and no 
evidence of fracture present. Stimson^ reports instances of complica- 
tions in the nature of rotation of the fractured internal malleolus about 
an anteroposterior axis, so that the broken surfaces came to lie just 




Fig. 566. — Bimalleolar fracture from abduction of the foot. Note the lateral displace- 
ment of the talus. 

beneath and parallel to the skin in a prominent manner. Another 
complication is the interposition between the tibia and the broken 
malleolus of a strip of periosteum. This I have observed many times 
in operating on these fractures. Other findings are the interposition 
of tendons between the internal malleolus and tibia, holding the 
fractured surfaces apart. In cases of severe violence with the added 



1 New York Med. Jour., January 26, 1889 and June 25, 1892. 



TIBIA AND FIBULA 



775 



compressive force of the body weight, as in falls, both malleoli are 
broken off, the two bones are separated at their lower ends, and the 
tains displaced laterally, is forced np between them. Additional 
lines of fracture involving the diaphysis of the tibia may be present, 
some of great extent (as shown in Fig. 571), and some of lesser extent, 
involving the anterior or posterior edge or lip of the articular surface 
of the tibia (Figs. 572, 573, 574, 575, and 576). 




Fig. .567. — Separation of the tibio- 
fibular ligament, the inner malleolus 
being dragged under the joint. The 
falus is displaced upward between the 
two brines. 



Fig. 568. — Oblique fracture of the lower 
end of the fibula with a plane entering ankle- 
joint. Note that the foot is dressed in 
marked inversion and yet the malleolus is 
not dragged down into place. This results 
from laceration of the external lateral liga- 
ment. The persisting displacement may be 
taken as an indication for nailing by open 
operation. 



Some of these fractures are open because the skin is stretched 
over the inner aspect of the ankle, or because it is torn by external 
objects or punctured by the fragment of the tibia in a continuation 
of the compressive force from the body weight. Posterior or anterior 
di.splacement of the foot and talus are rare, unless the corre- 



776 



FRACTURE OF THE BONES OF THE LEG 





Fig. 569. — Fracture of the external 
malleolus with separation of the tibio- 
fibular ligament. 



Fig. 570. — Healed separation of the 
ligament between the tibia and fibula. 
The injury happened years before and 
there is no trace of malleolar fracture. 




Fig. 571. — Fracture of both 
malleoli with a large fragment of 
the diaphysis broken off. 



Fig. 572. — Fracture of the internal malleolus 
with a split-off fragment on the anterior articular 
surface of the tibia, lipping fracture. 



TIBIA AXD FIBULA 



777 



sponding edges of the tibia are broken off, as is stated later in the 
paragraph on Lipping Fraetvu'e. 





Fig. 573. — Lipping fracture of the 
anterior tibial border. 



Fig. 574. — Unusual types of ankle fracture 
from longitudinal force in falls. The tibia is 
comminuted and there exists the so-called longi- 
tudinal fracture. 





Fig. 575. — Another type of longitu- 
dinal planes of separation with some in- 
volvement of the internal malleolus. 



Fig. 57G. — Fracture of the external 
malleolus and of tlic po.sterior border 
of the tibia. 



77S FRACTURE OF THE BONES OF THE LEG 

The dcfiuiiion of the fracture named after him, given by Pott in 1764 
in his hook, was that of fracture of the fibula three or four inches 
above the external malleolus with a tearing of the internal lateral 
ligament. In making a study of the ankles I found the following 
facts : 

Enumeration of Skiagraphic Studies of the Ankle Fractures. 

External malleolus alone 60 

External malleolus with fracture internal lateral ligament as evidenced in 

skiagram 31 

Internal malleolus alone 10 

Both malleoli 47 

Appreciable separation of interosseous ligaments . 10 

Both bones fractured above epiphysis 12 

Fracture external malleolus and epiphyseal separation 1 

Lipping fracture 16 

Marked displacement of astragalus: 

Inward 5 

. Backward 6 

Outward 25 

Result after setting — using tibio-astragalar axis as basis: 

Good 38 

Bad 27 

Analysis of these figures demonstrates that fracture of both malleoli 
is about two-thirds as common as fracture of the external malleolus 
alone, that it is five times as frequent as fracture of the internal mal- 
leolus alone, and about one and a half times as frequent as fracture 
of the external malleolus plus fracture of the internal lateral ligament. 
If external malleolar fractures alone and with internal ligament 
fracture are considered, they are twice as frequent as bimalleolar 
fracture. These figures also show that "lipping fracture" occurs in 
at least 10 per cent, of these ankle fractures and should be watched 
for in every case, and that good results, as demonstrated by the skia- 
grams, are not obtained in more than four-sevenths of the cases treated. 
Colvin,^ of St. Paul, analyzing 60 cases of ankle fracture, reports 
about one-fourth as consisting of fracture of the external malleolus, 
one-fifteenth of internal malleolus alone, and nearly one-half as bimal- 
leolar. He notes only 1 case out of 60 as consisting of fracture of 
the fibula and rupture of the internal lateral ligament, calling this 
the only true Pott's fracture in the series (fibula three inches above 
joint and rupture internal lateral ligament) (Figs. 577 and 578). 

Symptoms and Signs. — Erersion Fractures. — In pronounced cases 
with separation, the swollen, useless ankle, the foot held in abduction 
and eversion, and the prominence of the internal malleolus or the 
inner edge of the tibia are sufficient to warrant a diagnosis of ankle 
fracture on sight. It is not so easy, however, to state on mere sight 
whether both malleoli are broken or whether the external alone is 
separated and the internal lateral ligament is torn (Figs. 579 and 580). 
The attendant raises the foot and leg carefully from the bed and ascer- 

1 Surg., Gynec. and Obst., 1914, xviii, 99. 



TIBIA AXD FIBVLA 



tains the extent of abnormal lateral mobility at the ankle by holding 
the leg firmly abo^'e and fiexing.the foot laterally. If there is no marked 





Fig. 577. — An example of the 
classical Pott's fracture. Xote the 
slight lateral displacement of the 
talus. 



Fig. 578. — Lateral views of Pott's frac- 
ture. The damage sustained by the in- 
ternal malleolus does not show. Note that 
the talus is not displaced backward. 





Fig. 579. — Bimalleolar fracture two days 
old. Xote the swelling around the external 
malleolus and the backward displacement of 
the foot. 



Fig. 580. — Same as the preceding 
figure. Notice the greater aniount of 
swelling about the internal malleolus. 



780 FRACTURE OF THE BONES OF THE LEO 

motion on internal flexion, the question of separation of the internal 
malleolus is still an open one, but decision is usually reached quickly 
by a test for local points of extreme tenderness through palpation with 
the tip of the index finger, or the rubber tip of a pencil. Manipulation 
for obtaining of crepitus is always painful and should not be performed, 
as the observations of the points of tenderness are diagnostic. Occa- 
sionally the loose ends of the malleoli can be grasped between index 
finger and thumb and independent motion in them demonstrated. 
Spiral fracture of the external malleolus is less likely to give this 
finding. If posterior displacement of the foot is noted, the complica- 
tions of separation of the tibiofibular ligament, spiral fracture of the 
fibula, or fracture of the posterior border of the tibia must be con- 
sidered (see paragraph on Lipping Fracture). With fractures low 
down on the external malleolus the patient can sometimes walk by 
having the ankle held firmly, and many of these fractures are called 
sprains and overlooked. Bland-Sutton^ also believes that many of 
these are unrecognized and says that an articular fragment split off 
into the joint may unite viciously or lead to a chronic arthritis with 
adhesions, if it is unrecognized, and use of the ankle persisted in. 

Prognosis. — A small amount of displacement permits a good prog- 
nosis with intelligent treatment. Every case should be observed by 
a two-way roentgenogram after it is treated, to be sure that all errors 
of displacement are corrected. If manipulative reduction as given 
under treatment is not successful in a full sense, operative recourse 
should be considered. In instances of bimalleolar fracture with rup- 
ture of the tibiofibular ligament and great displacement of the talus 
and fragments, the prognosis, even with the best treatment, is grave 
as to full function. 

Considerable has been written lately concerning a mathematical cal- 
culation of the prognosis of ankle fractures from roentgenographic study, 
the lines or axes of weight-bearing force and the correct relation of 
joint surfaces being taken as criteria. If these are good — that is, if 
the joint surface of the lower tibial end and the talus bear a cor- 
rect relation to each other, and a line drawn through the weight- 
bearing axis of the leg from the anterosuperior iliac spine straight 
down through the patella passes through the middle of the talus 
body — the prognosis for a useful weight-bearing function of the foot 
and ankle is excellent. It is said that one can disregard the position 
of fragments if these points are satisfactorily established, but I believe 
that stand is not well taken; for the powerful supporting lateral 
ligaments of the ankle, attached as they are to the lower tips of the 
malleoli above, must be replaced in a position of relative balance and 
allowed to heal in that position before useful painless function can be 
hoped for, and this can only be accomplished by the replacing of these 
malleoli in normal position and reestablishment of the conformity 
of the tibio-astragaloid articulation. 

1 Lancet, February 7, 1914. 



TIBIA AXD FIBULA 781 

Of great importance also are the lipping fractures involving the 
tibia with posterior or anterior displacements of the astragalus. 

An anteroposterior skiagram may not show these, or a picture 
taken after reduction may show a good result as far as the restoration 
of the mortise is concerned, Avhich if further analyzed by a lateral 
view, would show a displaced lipped fragment of the tibia and give 
a poor prognosis for the full use of the ankle. The astragalus head 
rests firmly mortised between the two malleoli, which lock it in and 
hold the articulating surface directly under the lower joint surface 
of the tibia, which is the bone of weight-bearing. • As Skinner has 
advised,^ the anteroposterior skiagram should give us information 
in regard to the condition of this mortise, and the exposure should be 
made with the centre of the focus about an inch above the centre of 
a line drawn between the two malleoli, the foot being held at right 
angles to the leg. 

The author believes that close attention should be paid consequently 
to the exact findings of each ankle fracture, and each case should be 
treated conscientiously and intelligently according to the findings. 
Among the laboring class nothing so interferes with wage-earning as 
weakened-leg support, and the whole train of life consequent upon 
the ability to get about on two good feet is very different from that 
which follows the permanent and partial disability of a bad ankle. 
These fractures do have some permanent impairment of function 
even when treated by the very best methods devised to date, and 
each man so afflicted should be given the best attention to shorten his 
disability and should not be allowed to use the ankle until callus is 
hard enough and ligaments are firmly enough healed to bear his weight, 
and not cause a further interference with his wage-earning powder 
within a few weeks after he has returned to his occupation. The 
ankle fractures may mean in every case except those of the slightest 
crack a disability of three months, and in severe cases nine to fifteen 
months is not unusual. 

Treatment. — If the lower end of the fibula alone has been split or 
twisted by the trauma, treatment should attempt to hold the astragalus 
well up against the internal malleolus and then to drag the cracked or 
broken external malleolus over to its proper position by forced inver- 
sion, with dependence on such fibers of the external lateral ligament 
as are still intact (P'ig. 581). Dupuytren's splint of a heavily padded 
board applied from the knee to beyond the foot can often be employed 
immediately after the fracture is seen, and the foot started toward the 
desired position of inversion. The fault with the use of this splint 
has lain in the fact that not nearly enough padding has been used 
just above the ankle to permit the foot to be bandaged over and held 
in inversion. Each day the dressings can })e reapi)lied and more 
inversion obtained. This does not contemplate correction of marked 
posterior displacement. After a week's use of this splint a circular cast 

' Tr. Internal. Cong. Med., London, 1913; Surg., Gynec. and Obst., 1914, xviii, 2."JS; 
Arch, of Roentgen-ray, 1913, p. 345. 



782 



FRACTURE OF THE BONES OF THE LEG 



or a moulded plaster splint should be applied, as the swelling in the 
ankle will have nearly disappeared. Stimson's moulded splint, consist- 
ing of one strip down the back of the leg and another laterally to hold 
the foot inverted, is excellent. I have modified this by using but one 
piece about six inches wide starting over the head of the fibula, passing 
down the leg under the arch of the foot and 
over the dorsum just to meet the external wing 
on the top of the foot. This should be wide 
enough to come over the heel and furnish some 
support in an anteroposterior direction, and the 
foot should be held in the degree of inversion 
desired while the plaster hardens after appli- 
cation of a circular bandage. This splint is 
readily removed for inspection or dressing in 
case of open operation and can be reapplied 
by being bandaged as firmly as in the first 
instance (see Figs. 582 and 583). 

Teaching of treatment by inversion for ankle 
fractures has been wide-spread and often mis- 
interpreted and wrongly applied when a com- 
plete diagnosis of the lesion was not made. 
One case of suit for malpractice, which was 
based on the position in which the foot was 
dressed, was reported in the Journal of the 
American Medical Association.^ In this case 
the suit was based mainly on the fact that the 
defendant (the practitioner) did not treat the 
foot by inversion, the assertion being advanced 
that he was not familiar with this proper method 
of treatment. A splintering of the fibula and 
laceration of the ligaments was the acknowl- 
edged pathology. The doctor's defense was 
that on account of the patient's age, fifty-two 
years, and of the fact that when first seen and 
for three weeks thereafter his ankle was very 
ecchymotic and swollen, he did not put it in 
inversion at first, because of the swelling and 
later because bony union was already started 
and no good would be accomplished. The 
court sustained the doctor inasmuch as it was 
not proved that he had been negligent in the 
existing case, regardless of the conduct necessary 
in general treatment of these injuries under other conditions, in which 
the treatment given might have been complained of as being negligent. 
Should both malleoli be broken off, our method of treatment becomes 
a more difficult task. Here forced inversion alone is not sufficient, 



Fig. 581. — Treatment 
of fracture of the external 
malleolus by inversion of 
the foot in a plaster en- 
casement. 



1 Jour. Am. Med. Assn., Ixii, No. 18, p. 1599; Marchaud vs. Belin, Wisconsin, 147, 
N. W. R., 1033. 



TIBIA AND FIBULA 



783 



as, in bimalleolar fracture, we can always look for displacement of 
the astragalus either out or in, forward or back, according to the 
direction of the causative trauma; so the real treatment consists in 
returning the astragalus to the weight-bearing axis and then fixing 
the malleoli in some such way that they hold the astragalus in that 
position (Fig. 5S4). This can sometimes be done through manipula- 
tion and a subsequent application of plaster swathe or cast, but many 
cases require nailing to hold both sides in position. Where bimaheolar 





Fig. .582. — The author'.s moulded 
splint for malleolar fractures. 



Fig. 58.3. — Side view of the moulded 
splint for ankle fractures. 



fracture is complicated by rupture of the interosseous ligament and a 
separation of the lower ends of the two bones, with a possible forcing 
upward of the talus between them, nothing short of open opera- 
tion to press the two bones together, to return the talus to its 
proper articular position, and to nail on the two malleoli and the tibia 
to the fibula will preserve good function and prevent the wide painful 
ankle. After such operation or happy mechanical reduction in bimal- 
leolar fracture the foot should not be put up in adduction, but should 
rest at a right angle and be allowed a long immobilization that the 



784 



FRACTURE OF THE BONES OF THE LEG 



malleoli may unite firmly with a minimum of callus, and this callus i 
mature; also that the torn ligaments may reunite, a process which 





Fig. 584. — Healed bimalleolar fracture 
treated by a cast. The talus is in fair 
position under the tibia and there is ample 
callus cementing the malleoli. A better than 
average result. 



Fig. 585. — Bimalleolar fracture with 
outward displacement of the talus. 




Fig. 586. — Repair of the preceding by nails. Note the skin clips in the incision and the 
return of each malleolus to its normal position. 



TIBIA AXD FIBULA 



785 



takes longer than bony union, and a normal circulation of rest in the 
ankle may be established (Figs. 585, 586, and 587). When the splint 
is removed after six weeks, a very light massage and passive motion 
may be indulged in, but not to a point of pain at any time, and no 
weight-bearing on the foot should be allowed for two or three weeks. 
Then the weight may be gradually applied. If the attempt is painful, 
the fact is ample evidence that the callus is not yet matured and a 
further wait is necessary (Figs. 588 and 589). 

At the inception of weight-bearing, if the external malleolus has 
been the greatest sufferer in the fracture, the patient should be cau- 




FiG. 587. — The two ankles in preceding operation. Note that the bony points of the 
two malleoli on the injured ankle appear beneath the skin in their normal positions. 
Foot just out of cast, wounds long since healed. Loss of toes an old injury. 



tioned to hold the foot straight forward or with toes turned slightly 
in and the inner side of the heel and sole should be raised slightly. 
This holds the foot in better weight-bearing axis and helps avoid a 
yielding of the young callus in the fibula and the weakened internal 
lateral ligament. 

Malleolar Fractures Caused by Inversion of the Foot. — If the enu- 
meration above is referred to it is found that fracture of the internal 
malleolus alone occurs one-ninth as frequently as that of the external 
malleolus, and as this injury results from inversion, which may also 
cause bimalleolar fracture, this position at the time of injury must 
.50 



7SG 



FRACTURE OF THE BONES OF THE LEG 



be common also. The mechanism of isolated fractures of the internal 
malleolus is that of fall or compression from body weight against 
the talus, which is tipped inward by the inverted foot. The inner 
edge of the talus is pushed up against the inner corner of the 
ankle mortise, and the inner process of the tibia is broken off. For 
this result the inversion must not be great, because the pull of the 
external lateral ligament would also pull off the external malleolus. This 
may be avoided by a rupture of the external ligament, or the quickly 





Fig. 588. — Healed fracture of the 
external malleolus with separation of the 
interosseous ligament. A small fragment 
loosened from the outer edge of the tibia. 



Fig. 589. — Bimalleolar fracture with 
little displacement. It is almost im- 
possible to correct a fracture of this 
character by any means, and some 
thickening of the ankle must result. 



applied force from the fall does not make much pull laterally but 
exerts all its force in an upward and slightly inward direction (Figs. 
590, 591, 592, and 593). The split of the tibia depends on the amount 
of body weight and the tipping of the talus and the holding of 
the lateral ligament. The line of fracture may extend almost directly 
up through the diaphysis, or as the internal malleolus gives, more 
lateral stress is made on the external malleolus by the taut lateral 
ligament. The driving edge of the outer side of the talus acts 
to break off the outer malleolus also, causing bimalleolar fracture. 



TIBIA AND FIBULA 



787 



This separation of the fibula in tlie young may take place througli 
the epiphyseal area, as in the wrist. 




Fig. 590. — Fracture of the inner 
malleolus -n-ith much comminution of 
the tibia above. The talus is rotated 
outward a little, the fracture following 
a fall on the abducted foot. 




Fig. 591. 



-Fracture of the internal malleolus 
alone. 





Fig. .502. — Fracture of the internal 
malleolus alone from adduction violence. 
Note the upward displacement and the 
openinp: of the ankle-joint. 



Fig. 59.3. — Fracture of the internal 
malleolus with e version of the foot, the 
external malleolus being intact. This is a 
rare type. 



788 



FRACTURE OF THE BONES OF THE LEG 



The pathological findings are similar to those of external malleolar 
or bimalleolar fracture, and the diagnosis is made by means of the 
points of tenderness or the loose fragments on the tibial side. Treat- 
ment is the same as in the preceding fracture reversed, if the internal 
malleolus alone is broken. If the tibiofibular ligaments are ruptured, 
or both malleoli are split off and there is a wide ankle, the very best 
results are obtained by the attendant nailing each side on in its 
proper position and putting up the foot in a moulded splint or cast 
in a normal position, that is, straight as to its weight-bearing axis 
in relation to the talus and forward in the right position from the 




Fig. 594.— Healed fracture of the 
inner malleolus, treated by plaster 
splint. There is considerable callus 
thrown out beneath the raised 
periosteum, some of which has in- 
vaded the joint. Function was 
poor but would improve. 




Fig. 595. — Operative repair of fracture 
of the internal malleolus and the posterior 
border of the tibia (which does not show in 
this view). Nailing reduces the amount of 
callus to a minimum. 



lateral axis (Figs. 594 and 595). I have several of these operated 
cases working daily, who obtained excellent and painless functional 
results. In some the nails have been imbedded over three years and 
caused no trouble. Some permanent thickening of the ankle results, 
even with early and careful reposition, because of callus formation and 
thickening of the repaired ligaments coupled with circulatory changes. 
Fractures of the Articular Surface of the Tibia Anterior and Pos- 
terior. Lipping Fractures.^Besides the mathematical calculation 
of position of the talus by a line drawn through the long axis of 
the tibia, one must take into consideration fracture of the extreme 
edge or lip of the articular surface of the tibia. By this I mean a 



TIBIA AXD FIBULA 789 

splitting off of a wedge-like piece, usually of the compact bone alone, 
the line of fracture starting at the joint and extending upward along 
the shaft for a varying distance of one-half to two inches or more. 
These are much like the sprain fracture at the wrist and are caused 
by a similar mechanism, i. e., wedging force upward by the talus, 
which force may be in a direct line upward or at a varying angle and 
directed toward any side of the lower end of the tibia, depending on 
the position of the foot at the time of the trauma and the additional 
pulling, tearing out stress of the capsular ligament and tibiofibular 
posterior ligaments, with torsion on the bone surface. To these I 
have applied the term "lipping fractures." The importance of the 
posterior lip particularly has long been known and was described in 
the past as the third fragment in ankle fractures. Astley Cooper 
called it the external intermediate fragment; Tillaux, the classic frag- 
ment, etc. Older authorities as Earl Adams, Dupuytren, ]\Ialgaigne, 
and Hamilton considered the posterior luxation of the foot the most 
important point and the ligamentous rupture and malleolar and pos- 
terior fragments accessory. Destot^ states that he has insisted on this 
posterior fragment for sixteen years, regardless of its primary or second- 
ary occurrence because of its influence on treatment and prognosis. 
He entitles it the "third malleolus. '^ If the tibiotarsal equilibrium 
is not changed, he believes that an osseous cicatrix on the joint surface 
causes arthritis or a spicule may interfere with tendon action or be 
the source of reflex trouble. When the posterior fragment is not 
displaced, it is negligible. Destot collected 172 cases of fracture of 
the posterior margin, 2 of which were isolated, 4 combined with the 
internal malleolus, and 24 others of the anterior margin. If these 
fragments are not replaced, although the talus may be situated 
quite perfectly anatomically and the fracture of either malleolus be 
but a mere split, a great interference in function results. This out- 
come is explained by the fact that under this misplaced shell of bone 
shoved down in front of the ankle-joint at some quarter of its circum- 
ference callus is thrown out which later, by its presence and possible 
adherence to capsular ligament or the talus, causes marked inter- 
ference with full flexion or extension of the ankle-joint, and provokes 
much pain after use of the joint by mechanically impinging against 
the talus. Such ankles may show perfect alignment of malleoli 
and talus and yet be extremely painful after mild use. These 
lipping fragments should be searched for carefully, both clinically 
and in the skiagram, and replaced by hyperextension or hyperflexion 
at the time the fracture is set. If they cannot be reduced by manipula- 
tion, I believe they should be nailed on in correct position through a 
small skin opening, after which, if malleolar fracture is present, the 
foot can be put up in the proper position to meet the demands of the 
case. I find this condition mentioned by Robert Jones.^ 

The author's study shows that displacement of the talus, when 

1 Lyons Chir., 191.3, p. 256-391. 

2 Am. .Jour. Orthop. Surg., 191.3, xi, .314. 



'90 



FRACTURE OF THE BONES OF THE LEG 



its changed position is marked enough to be called a displacement, 
is five times as frequent outward as it is inward or backward, when 
all types of fractures, whether of one malleolus or both are considered. 
Where both malleoli are broken, a putting of the foot in adduction 
alone would not be sufficient, even if the talus were displaced 
outward five times as frequently as any other direction; but, as 
expressed before, the malleoli must be returned to normal position, 
and then, if it is necessary to retain the replaced dislocation of the 
foot, it should be put up in adduction. If the malleoli are nailed on, 
the foot can be held in marked adduction without fear of disturbing 
the replaced malleoli and every opportunity given to the important 
internal lateral ligament for a strong healing. 




Fig. 596. — An example of os trigonum which may be»mi3taken for a small bone fragment 
after ankle injury. See Fractures of the Talus. 



In 1900 Bondet^ concluded that the posterior displacement of the 
foot in malleolar fractures is produced: first, by dislocation of the 
tibiotarsal mortise; second, by combined action of weight and mus- 
cular contraction; third, often by the existence of a posterior tibial 
fragment — the presence of which is not revealed except by a skiagram 
(Fig. 596). 

In 6000 radiographs from the clinic of the Charite at Berlin, Pels^ 
did not find a single case of pure tibiotalus luxation — i. e., with- 
without fracture — as in every case either the anterior or posterior 
border of the tibia or both were fractured. In 1907 Grashey,^ in 
1500 roentgenograms, found 4 of the posterior tibial margin, and a year 

1 Lyons, 1900. 2 Berl. klin. Wchnschr., 1905. No. 5. 

^ Fortschr. a. d. Geb, d. Rontgenstrahlen. 



TIBIA AXD FIBULA 



•91 



later INIeissner/ in Bruns's clinic, stated he had seen 19 cases: 1 with 
isolated fracture of the posterior tibial margin; 8 with fracture of 
both malleoli; 1 with fracture of the internal malleolus; 5 with frac- 
ture of the fibula; 4 with epiphyseal separation. 

Later, Chaput- noted 42 cases in 136 skiagrams of malleolar frac- 
tures and says that from a clinical point of view the small fragments 
interfere with extension and are the origin of hyperostoses, while 
large fragments cause a posterior subluxation of the talus. Their 
reduction is difficult, and they often complicate ankylosis in bad 
position with considerable hyperostoses. 

Destot,^ in 1911, gives as signs the pointing forward of the tibia 
and the difficulty of reducing and maintaining the reduction. He 




Fig. 597. — Vertical fracture of the posterior edge of the tibia. 



believes that the marked enlargement of the internal malleolus and 
the rare possibiHty of feeling the tibial fragment in the retromalleola;r 
depression are diagnostic, and suggests that they be treated by: first, 
csteotomy of the fibula; second, a cutting off of the posterior tibial 
surface by an osteotome introduced along its posterior wall; third, 
open operation. 

In the same year Quenu"* reported 15 cases as follows (Fig. 597): 
1 of posterior margin of the tibia alone; 2 accompanied by malleolar 
fractures; 3 accompanied by fractures of the upper end of the tibia. 



' Beitr. z. klin. Chir., 1908, Ixi. 

' Traumatisme du Pied et Rayons X. 

* Fractures Marjrinales Posterieures, Rev. de C'hir., 1912. 



Monograph, 1899. 



792 FRACTURE OF THE BONES OF THE LEG 

Stimson considers the lipping break of the tibia as compHcation 
of Pott's fracture and in 1908 had never seen a recent case — all being 
old. He raised the fragment in 2 cases, corrected the displacement, 
and obtained a useful foot. In 1 he removed the articular surface 
of the tibia and leveled off the astragalus, getting a bony union with 
a good result. From the prognostic standpoint the lipping fracture 
is a lesion of the greatest importance, and in old cases the advisability 
of recourse to operation is imperative. 

Mechanism.^ — Almost all are caused by a slipping or a fall with the 
foot in hyperextension and often abducted and a tearing out of the 
articular border of the tibia by the posterior articular and tibiofibular 
ligament, accompanied by a crushing force upward and backward 




Fig. 598. — Lipping fracture of the posterior tibial border with fracture of the external 
malleolus and rupture of all the ligaments which permit an extreme backward disloca- 
tion of the whole foot at the talocrural joint. 

transmitted by the talus. The theory is further advanced that 
after fracture of the fibula a continuation of the line of force now not 
meeting resistance comes against the lip of the posterior articular 
surface and chips it off. This theory is very plausible, but does not 
explain cases of isolated fracture of the posterior or anterior lip. Frac- 
ture of the posterior lip alone has been considered very rare. Quenu 
finds but 3 cases to which he adds a fourth, and Plagemann mentions 
finding but 2 cases in eighteen years of practice. 

Examination generally shows painful extension or flexion, and though 
an anteroposterior roentgenogram may show no trace of fracture, 
the lateral view shows the lines in the tibia (Fig. 598). Clinically, 
it is quite impossible to obtain a point of extreme local tenderness 
over these isolated lipping fractures or to obtain crepitation, but in 



TIBIA AND FIBULA 793 

so-called Pott's fracture, with marked posterior displacement of the 
foot and the absence of injury or deformity in the tarsal bones, one 
should suspect these breaks. ^Yithout a skiagram and where the 
lipping fracture exists with little displacement of its fragment one 
may rely partly on the presence of an extended ecchymosis along the 
posterior surface of the ankle or a point of extreme tenderness to 
pressure under the calcaneus tendon in the depression back of the 
malleoli. The amount of displacement of the foot seems to give no 
key to the possibility of lipping fractures; the amount of separation 
of the tibiofibular joint or the laceration of this ligament may give 
indication, but the surest means of detection is careful study of the 
dried roentgenogram. Posterior displacement of the foot does not occur 
in ordinary Pott's, and where it does we must consider clinically that 
something more has happened in the ankle area than mere fracture 
of the fibula. If the fibula is broken three or four inches above its 
lower end, if the internal lateral ligament is ruptured at the same 
time, or if the tip of the internal malleolus is pulled off, we shall not 
get a posterior displacement of the foot. If all the soft parts around 
both malleoli are severed, if both lateral ligaments are cut, there will 
be no posterior displacement of the foot. 

If then, we find such posterior foot displacement, what must we 
consider? A displacement backward of the talus can only occur 
when the external malleolus is freed fully from the external side of 
the lower end of the tibia. Should both malleoli be broken and the 
tibiofibular junction and ligament remain intact, no posterior dis- 
placement presents itself, although we might find all degrees of internal 
or external displacement. To obtain the freedom of the external mal- 
leolus, then, we must have either a fracture very low down on the 
external malleolus, which allows the lower fragment, with its attached 
strong ligaments, to slip backward, or a diastasis of the tibiofibular 
junction with laceration of its ligament, or possibly a fracture of the 
fibula high up with its line extending down into the tibiotarsal joint. 
There seems to be little doubt that fracture of the posterior lip of the 
tibia of varying degree is caused by a further action of the force of 
separation of the tibiofibular ligament, which, being stronger than 
the bony surface into which it is inserted, pulls out the corner of the 
tibia and preserves its own fibers intact but allows the separation 
and displacement of the talus. To this is added, of course, lesions 
of the two lateral ligaments or the malleoli. The foot, in so being 
flisplaced posteriorly, drags with it, in practically every case, its 
malleoli. Hence we conclude that fracture of the posterior tibial lip 
alone is not sufficient to allow posterior displacement of the foot, 
even when accompanied by malleolar damage, unless the external 
malleolus is freed as mentioned. 

Treatment. — Treatment for all ankle fractures should be promj)t 
rcfluction under anesthesia, the possible exceptions being those cases 
^Teatly traumatized and swollen beyond manipulation. If lipping 
fragments or sharply pointed malleolar fragments threaten to necro- 



794 FRACTURE OF THE BONES OF THE LEG 

tizc through the skin, they should be reduced at once. Old fractures 
may he reduced after three or four weeks by manipulation or by 
oj)en oi)eration, consisting of osteotomy of the fibula, operation for 
removal or replacement of marginal pieces, perhaps by their being 
nailed on, or, in severe cases, operation on the articular surface of the 
tibia accompanied b}^ fibular osteotomy and a clearing out of the callus 
in the tibiofibular ligamentous area. Other cases may be best handled 
by a leveling operation on the head of the talus, with replacement 
in the weight-bearing axis or a complete astragalectomy. 

FRACTURES OF THE FIBULA. 

Fractures of this bone alone are rare except at the lower end. These 
were considered under the heading of Ankle Fractures. 

Fracture of the upper end of the fibula alone is caused by direct 
violence, or by muscular contraction of the biceps femoris muscle. 
Adduction of the leg may result in sprain fractures and epiphyseal 
separations of the upper end. The line of fracture is usually trans- 
verse, or the head of the bone may be comminuted and much dis- 
placed (Fig. 599). It is drawn upward by the biceps and is difficult 
to restore to position. Flexion of the leg may relax the biceps enough 
to permit full reduction. Sprain fractures and epiphyseal separations 
do not result in much separation. 

Diagnosis. — The diagnosis is made by the finding of the loose frag- 
ment, pain, crepitus, and interference with knee action (Fig. 600). 
The leg is usually held in a flexed position. Sprain fractures are 
diagnosed by the ecchymoses, the recurring point of tenderness to 
pressure, and the roentgenogram. The upper end of the bone lies 
without the knee-joint, and swelling or hemarthrosis does not often 
occur after fibular fracture. The most serious complication is injury 
of the external peroneal nerve as it winds around the head of the bone. 
It may be stretched, with temporary suspension of function and 
anesthesia in the leg, or it may be pressed and irritated, with resultinfj 
severe pain in the leg. Paralysis of the sural branches may come 
on immediately if the nerve is severed, or late if it is compressed in 
callus. Either condition is an indication for open operation to free the 
nerve or unite it when it is completely torn. Mild pressure symptoms 
usually disappear in ten or twelve days. I saw one case in which 
the peroneal paralysis was not clearly manifest until four months after 
the fracture. Operation was refused. It seemed that the paralysis 
could have been caused by the inclusion of the nerve in the callus 
with a very slowly proceeding pressure many weeks after bony union 
had taken place. 

Treatment. — Treatment of fracture of the upper end of the fibula 
depends on the displacement. If the upper fragment is drawn upward, 
or the peroneal nerve is injured, open operation for reduction may 
be necessary. Many cases can be reduced and held by the attendant 
flexing the knee and applying a light moulded plaster splint. A 



FRACTURES OF THE FIBULA 



•95 



slight displacement or a sprain fracture can be strapped, and the 
patient can walk on the leg inside of a week. Little disability follows 
union without replacement, unless the nerve is involved. 

Fractures of the shaft are causetl by direct violence or by ligamentous 
and muscular pull in twisting of the foot. There is little displacement, 
because the tibia is intact and the interosseous membrane holds tlie 
fragments. The symptoms are pain in the leg after walking and a 
localized point of tenderness when the shaft of the fibula is examined 
by the fingers run down its length. There are often ecch\'motic spots 





Fig. 599. — Complete fracture of the 
upper end of the fibula without separation 
caused by direct A-iolence. 



Fig. 600. — Comminuted fracture of 
the fibula alone caused by compression 
and torsion. 



where the violence has acted. The bone may be partly comminuted 
(Fig. 001 j. Treatment is furnished by a plaster encasement which 
includes the foot and wards off torsion stress on the bone in walking. 
Many of the.se fractures, especially transverse fracture with no dis- 
placement, remain undiagnosed until the continued pain and soreness 
after walking lead to the taking of a roentgenogram. 

Fpiphyseal separation at the lower end of the fibula alone is not 
uncommonly found in routine Roentgen-ray examination of ankle 
injuries (Fig. 602). It is caused by ligamentous pull on the lower 



^96 



FRACTURE OF THE BONES OF THE LEG 



end of the bone in both inversion and eversion ankle injuries. There 
is usually little separation. Treatment is supplied by an internal 





rr) 



Fig. 601. — Oblique fracture of the 
lower end of the fibula above the epiphy- 
seal line caused by direct violence. Tibia 
not broken and ankle mortise normal. 
This type is often diagnosed as sprain. 



Fig. 602. — Epiphyseal separation 
of the lower end of the fibula, little 
displacement, but persistent pain and 
disability. 



splint of padded wood or the moulded plaster splint which holds the 
foot in partial adduction. Walking should be prohibited at least four 
weeks. 



CHAPTER XXVI. 
DISLOCATIONS OF THE KNEE. 

For the anatomy of the Hgaments of the knee-joint, the crucial 
Hgaments, cartilages and the patella, the reader is referred to Fractures 
of the Tibia and Fibula and the Patella. 

Dislocations of the knee are not common. I find in a compilation 
of 796 dislocations admitted to the Cook County Hospital, that 24 
involved the knee, and a few of these were really dislocations of the 
semilunar cartilages. One of the knee dislocations was in a child. 
Classification of knee dislocations is made on the direction toward 
which the tibia is displaced, namely, forward, backward, outward, 
and inward. There are also conditions of subluxation and luxation 
by rotation which may combine with the other forms. Forward dis- 
location occurs in about half of all knee luxations, backward dis- 
location in one-third of all, outward, inward and rotatory luxations 
accounting for the remainder. Simultaneous dislocation of both 
knees has been reported. The character of the cause of pure knee 
luxations frequently leads to open wounds and to injury of the pop- 
liteal vessels. The dangers of gangrene of the extremity and infection 
of the large knee-joint are therefore to be considered, and many 
amputations after knee luxation have resulted. 

Forward Dislocations. — The limit of extension of the knee is gov- 
erned by the lateral and posterior joint ligaments and the anterior 
crucial ligament. The causes of luxation are direct violence applied 
to the thigh or leg, or indirect violence when the leg is held fixed. 
Direct violence on the leg, pushing it forward, or on the thigh above 
the knee, pushing it backward, are the common causes. The patient 
may get his leg caught in a wheel or a belt and have it twisted forward, 
or fall in a hole, and have the body momentum carry the femur back- 
ward into dislocation. Several cases have been reported from hyper- 
extension of the knee in elevator accidents. Passengers in a falling 
cage sustain a sudden severe hyperextension of the knee when the 
cage strikes the bottom. Stimson reported 1 such case,^ and Eames^ 
5 cases in a group of 18 men who were in a car which dropped sixty 
yards down a mine shaft. The case shown in Fig. 00)^ occurred in a 
teamster who was knocked off a high seat by a collision with a street 
car. He sustained also a skull fracture. 

Pathology. — The luxation may be complete or incomplete, more 
often the latter. Open dislocations also frequently result from severe 

' P>actures and Dislocations, 7th ed., p. 851. 
2 British Med. Jour., I'JOO, i, 908. 



'98 



DISLOCATIONS OF THE KNEE 



direct violence in power belt and wheel accidents, the wound being 
caused by the trauma or resulting from the overstretching of the 
soft parts on the condyles of the femur behind the joint. Incomplete 




Fig. 



603. — Uncomplicated complete anterior dislocation of the knee, 
for traction applied over the padded ankle. 



Note the bands 



anterior luxation need not rupture the capsular ligament at all, as 
far as any clinical evidence shows. Autopsy findings confirm this 
fact. I have seen one incomplete anterior luxation in a large man 
which did not cause even a demonstrable amount of fluid in the knee- 




FiG. 604. — Lateral view of a complete anterior dislocation of the knee shown in Fig. 
603. Note the skin line showing the bulging forward of the knee and the angular posi- 
tion of the patella. 

joint, although it was out of place over twenty-four hours. The cap- 
sule of the joint could not have been ruptured, because there were no 
hemarthrosis and no skin ecchymoses. Between the articular surface 



FORWARD DISLOCATIOXS 799 

of the tibia and the femoral condyles in incomplete hixation there is 
still an area of contact, and the anterior crucial ligament alone may 
be ruptured. Complete anterior luxation necessitates the displace- 
ment of tibial surface above the lower end of the femur — usually a 
distance of one or two inches (Fig. 604). The lateral and posterior 
ligaments of the joint, both crucial ligaments, and possibly the ham- 
string tendons are torn. Rarely the calf muscles are lacerated and 
the popliteal nerves are ruptured. In open dislocation we may expect 
injury of the popliteal artery and vein; their rupture has been recorded 
in closed luxations. When the femur appears through the skin open- 
ing it may show evidence of the pulling out of the posterior ligament 
from its surface, small pieces of bone being avulsed. The ligament 
may rupture at other points and permit the femur to escape through 
the rent. 

Injuries of the popliteal vessels vary. The inner coats may be rup- 
tured with damage of the adventitia, and after reduction an aneurism 
develops. If the vessel is stiffened it may rupture in part, especially 
in calcified areas of the wall, or a thrombus may form in the vein after 
reduction. Occasionally the vessels are so compressed that circula- 
tion through them ceases during the continuance of the luxation, but 
is renewed without untoward effect when reduction eases them off. 
If the knee-joint becomes infected in open luxation, pyarthrosis with 
a stiffened joint or a subsequent amputation may be the outcome. 
The amputated legs have given excellent opportunities for the exami- 
nation of the pathological lesions. 

Fracture of the spines of the tibia and dislocation of the semilunar 
cartilages may accompany the luxation (see Fractures of the Tibial 
Spine). ^Miiller^ reported a forward luxation in a woman aged twenty- 
five years, who fell off a bicycle and struck her knee on the pedal. 
The medial spine of the tibia was broken off and the anterior crucial 
ligament was ruptured, but the semilunar cartilages and the capsule 
were uninjured. A hemarthrosis was present. Arthrotomy was done 
at once to remove the bone fragment and a good result followed in 
six months. Gotjes- reported 23 cases of rupture of the crucial liga- 
ment which were found in the literature; 7 of these w^ere in Tillman's 
clinic. 

Symptoms. — In complete forward luxation the leg is extended and 
lies on a higher level than the thigh. The prolonged longitudinal 
axis of the leg strikes above the femur. Behind can be felt the bulging 
condyles of the femur, and in front the upper articular surface of the 
tibia, with the patella riding against it tipped at any angle up to 90 
degrees. Posteriorly the skin and hamstring tendons are tense, 
anteriorly the skin lies in a deep fold behind the upper tibial surface. 
Swelling and hemarthrosis are usually prompt complications in com- 
plete luxation. The joint may be quite freely movable if all the liga- 

' Beitr. z. klin. Chir., 1914, xciv. 221. 

2 Deutsch. Ztschr. f. Chir., 1913, Bd. cxxiii. 



800 DISLOCATIONS OF THE KNEE 

ments are torn; if they remain intact it is fixed, and attempts to flex 
the leg are painful and resisted. Lateral movements and even hyper- 
extension may be present. Incomplete luxation gives less pronounced 
findings, which may be marked by swelling and joint distention, ihe 
roentgenogram will decide the positions of the tibia and emur, or if 
subluxation is suspected, the leg may be given treatment looking toward 
reduction before it is put to rest and the swelling reduced. Open 
dislocation usually has a posterior wound, transversely across the 
femoral condyles, which protrude or are seen in the opened joint. Nerve 
and vessel injury are difficult to diagnose unless the vessel is torn m 
an open wound and hemorrhage ensues. Tinglmg and numbness in 
the foot indicate nerve pressure, lack of sensation, nerve avulsion. 
The dorsalis pedis artery is the best guide for an intact arterial trunk. 
Nerve and vessel injuries may have delayed symptoms and begmrimg 
gangrene may not be evidenced until several days after reduction. 
Paralysis of muscle groups may also be uncertain for some time after 
luxation and may be accompanied by atrophy and trophic ulcerations 

on the ankle and foot. . , t a •+v,^„t „,,„ 

Treatment.-Reduction can sometimes be performed without any 
anesthesia by simple traction in the long axis of the leg, the thigh 
bebg counter-extended. A broad bandage around the padded anlde 
gives sufficient hold to make traction by its loose ends the joint 
readily sliding back into place. If this simple method of reduction 
fails the leg can be hyperextended and drawn downward whie direct 
ptessure is made backward on the head of the tibia. R^k of add.tiona 
iniury of the vessels and nerves is caused by this procedure, and 1 have 
never found it necessary. A posterior padded splint or a plaster encase- 
ment from hip to toes will hold the reduction the eg being slightly 
flexed After a gentle reduction no increased swelling ot the knee- 
joint need be anticipated, but if a circular plaster encasement .s used 
it should be cut out over the anterior part of the knee that the atten- 
dant may observe the condition of pressure Immobilization is neces- 
sary for four to sk weeks to give the crucial and joint ligaments an 
oDDortunity to heal. Weight-bearing on the leg is deferred until the 
St feeScure and is not'at all painful. When walking is attempted 
too soon the healing ligaments stretch, the joint becomes uncertain 
and some disability is permanent An elastic k?ee-cap shou d be 
worn for six months to a year and every precaution must be taken 
to avoid exaggerated motions of the joint. A slight partial restriction 
of knee-joint action is a common result in uncomplicated cases. 

In cases of vessel injury with gangrene started it is better to Perform 
early amputation above the knee than to wait for aline of demarca- 
tion and toxic absorption which lessens the chance of recovery. Open 
luxation has a grave prognosis both as to life and loss of the leg. 

Ba^ward Dislocations.-Backward knee luxation is less common 
than forward. Velpeau made the first study of the condition and later 
Ma?ga°gne gathered 80 cases of knee dislocation, only 12 of which 
were backward. Isolated cases have appeared in the literature since. 



BACKWARD DISLOCA TIOXS 



SOI 



A recent study was made by Hardoiiin^ (Fig. 005). lie finds only 
17 cases in the French literature since ]\lalgaigne. Direct posterior 
dislocation may be complete or incomplete. The luxation may also 
be back and outward or inward, and like anterior displacement, 
accompanied by rotation. 

The causes are direct and indirect violence, the former acting on 
the tibia or femur and the latter acting by the force of body weight 
driving the thigh forward while the leg is held fixed. Wheel accidents, 
especially in younger persons, cause dislocation by the catching of 
the leg between the spokes and body of the vehicle, the knee being 
forced into luxation by the leverage of direct violence. Shafting and 
machinery-belt injuries account for many luxations of adults. 

Pathology. — Hardoiiin states that there are 27 
cases of posterior dislocation in which autopsy 
or open operation have given definite information 
of the pathology; 13 of these were direct dis- 
location backward. The head of the tibia slides 
backward, directed outward and inward, or inward 
by the intact and holding ligaments. Incomplete 
posterior luxation is possible with an intact 
anterior ligament. Complete dislocation is im- 
possible unless the posterior crucial ligament is 
ruptured, but the anterior crucial and joint liga- 
ment may be stretched and elongated. All clin- 
ically known forms of knee dislocation have 
been produced experimentally on the cadaver, 
and the findings indicate that there is preser- 
vation of much of the ligamentous structure, 
especially of the lateral ligaments. A con- 
comitant luxation of the fibula on the tibia has 
been found in some cases. If all ligaments are 
destroyed, the head of the tibia can be carried 
in any direction, the joint being very loose. 
The usual type, however, preserves a consider- 
able part of the joint surroundings. In a case 
in which amputation was performed by Bernard 
there was a fracture of the internal tuberosity of the tibia, the 
lateral ligaments were intact, the posterior capsular and crucial 
ligaments were torn, and the popliteal vessels were obliterated. 
The popliteal vessels may be torn completely or in their inner coats 
alone, and the tubercle of the tibia may be avulsed by traction 
of the patellar tendon (Fig. 606). The patella may also be fractured, 
and open wound into the joint from direct violence has been 
reported. 

Other complications consist in fracture of the femur or tibia, rup- 
ture of the quadriceps muscle, and gangrene. 




Fig. 605.— Outline of 
Hardoiiin's case of back- 
ward dislocation of the 
knee. Note the promi- 
nence of the lower end 
of the femur. 



' Rev. de Chir., xlviii, S47. 



51 



802 



DISLOCATIONS OF THE KNEE 



Symptoms. — The knee is thickened in its anteroposterior diameter, 
and in complete dislocation the leg is shortened and lies in full exten- 
sion. Axial lines through the femur and tibia fail to meet, and the 
leg may be deflected to one or the other side according to which 
ligaments remain intact. Palpation discovers the rounded surfaces 
of the femoral condyles in front of the joint with the tense skin over 
them and a depression below them in place of the tibia. Displace- 
ment of the patella may carry it to one side or the other, or it may lie 
pressed flatly into the intercondyloid notch. On the posterior surface 
the sharp edge of the displaced tibia is prominent, the overlapping on 




Fig. 600. — Anteroposterior view of complete anterior dislocation at the knee. 
Looked at from behind. 



the femur varying from one to three inches. Incomplete dislocation 
with the head of the tibia in partial contact with the femoral cond;^les 
gives less pronounced findings. When all ligaments are torn, espe- 
cially both crucial ligaments, the joint is easily moved and is unstable. 
Retention of part of the ligaments causes a rigid joint, with passive 
motion possible away from the side of damaged ligaments. 

In a few instances the dislocation has never been reduced and a 
fairly useful false joint has developed between the bones of the knee. 
Karenski^ reported a case in a thirty-two-year-old woman. The 

1 Arch. f. Chir., 1886, xxxiii, 525. 



BACKWARD DISLOCATIONS 



803 



dislocation had been present sixteen years, and the function was very 
good. The diagnosis of accompanying fracture is often difficult, and 
roentgenogram in two directions should be employed. 

Treatment. — Treatment in recent luxations consists in reduction 
by flexion and traction forward on the leg (Fig. 607). Hardoiiin found 
that reduction was easy but that a subluxation occurred as soon as 
the traction was released. If this tendency is present, the leg should 
be placed in Buck's extension with a twenty pound weight applied 
for three or four weeks. The ligaments heal, and slight active motions 
are permitted, so that in six to eight weeks the patient can safely 
begin walking (Fig. 60S). Mauclaire's case was one of rupture of 
both crucial ligaments, and thc}^ were sutured by open operation in 
spite of the large hemarthrosis present. A cast was applied and after 
its removal in forty days some subluxation backward of the knee was 
still present. There was also a fibrous ankylosis. 





Fig. 607. — Subluxation backward of 
the knee w-ithout rotation. 



Fig. 608. — Outline of Mauclaire's case 
of subluxation backward. 



Irreducible posterior and old dislocations are treated by arthrotomy. 
A long semilunar incision (Hahn's) over the front of the joint permits 
access to the interior. Displaced cartilages, bone spicules, and torn 
ligaments may be removed and the joint brought into position. The 
operator should use every precaution to avoid wounding or abrad- 
ing the joint surfaces. Old dislocations may be reduced by simple 
arthrotom\- combined with tenotomy of the hamstrings, or a complete 
arthroplasty. Formation of a new joint surface modelled out of the 
head of the tibia covered by an interposing flap of soft parts may be 
the best ])rocedure. The extent of the operative interference depends 
on the age of the luxation and on the deformity. 



804 l)i:SLOCATWNS OF THE KNEE 

Lateral Dislocations. — Inward dislocations are extremely rare. 
They are caused by excessive violence and may be accompanied by 
fracture of the tibia or femur, and are therefore considered from the 
standpoint of fracture. Complete inward dislocation involves tearing 
of the internal lateral ligament ahd possible injury of the hamstring 
tendons and popliteal vessels. Reduction is made without difficulty 
by traction on the leg and direct pressure. One case of subluxation 
and fracture of the tibial tuberosity which was under my care was 
easily reduced by my applying traction on the Hawley table and direct 
pressure over the deformity on the inner side of the knee, replacement 
occurring with a muffled snap. After-treatment consists in immob- 
ilization for four to six weeks in a moulded splint, the leg being 
placed in a very slight degree of flexion. Walking must be cautiously 
begun, and the knee should be supported by an elastic bandage, or 
an outside leg iron, so that abduction movements of the foot will not 
cause recurrence or lacerate the weak ligament. 

Outward Dislocations. — Outward incomplete luxation, usually with 
some rotation occurs more often than inward. Complete outward 
dislocation is rare. The causes are twists of the leg or falls on the leg 
in abduction. The pressure of a heavy weight against the thigh when 
the leg is fixed has also caused this lateral displacement. Fowler^ 
reported a case in a forty-year-old man who was pulled from a wagon 
a distance of three and a half feet. The leg was in flexion and some- 
what abducted, the inner tuberosity of the tibia was in contact with 
the external condyle of the femur, and there was present a slight 
amount of external rotation of the leg. Active motion was absent, 
and the roentgenogram confirmed the diagnosis, showing a fracture 
of the external tuberosity of the tibia. Reduction was accomplished 
by direct traction and pressure over the head of the tibia. An exitus 
followed in eleven days from lobar pneumonia, and examination of 
the knee was made. The joint was distended by a bloody fluid, the 
outer half of the head of the tibia was comminuted, and the external 
lateral and anterior ligaments were torn across. The internal lateral 
ligament was but partly ruptured, and the posterior ligament, popliteal 
vessels and nerves were intact. 

The vastus internus may be ruptured, as also the crucial ligament 
Hardoiiin's experiments demonstrated that outward dislocation is 
impossible without rupture of the anterior crucial ligament. The 
patella may be displaced laterally and resist attempts at reduction. 
Injury of the popliteal vessels has been recorded. 

Symptoms. — The knee may be abducted or adducted, and is generally 
partly flexed. In Duguet's case^ the leg was flexed to an angle of 60 
degrees. There is pain and loss of function, so that active movements 
are not possible. A bayonet deformity exists at the knee, the internal 
condyle of the femur appearing on the inner aspect of the joint covered 
by a crease in the skin, and the displaced tibial head projects on the 

1 Jour. Am. Med. Assn., 1911, Ivii, 2124. 

2 Bull, et mem. Soc. de Paris, 1914, xl, 36. 



ROTATORY DISLOCATIONS 805 

outer side. Presence of the patella over the outer aspect of the joint 
may mask the sharp contour of the tibia. Some external rotation of 
the leg is also present; in wide lateral displacement there is more 
rotation and backward position of the external tuberosity of the tibia. 
The long axis of the femur and tibia do not correspond; that of the 
tibia lies outside. 

Treatment. — Reduction is simple, by traction on the leg and pressure 
inward over the tibia. If there is difficulty in reduction, mechanical 
extension and sufficient force to unlock the two bones must be used. 
After reduction a Buck's extension can be employed for two weeks 
with fifteen to twenty pounds weight, and a plaster dressing is then 
worn for a couple of months to permit firm cicatrization of the 
lacerated ligaments before use is attempted. Duguet found that 
after reduction of the knee luxation the patella remained dislocated 
laterally, probably being held by violent contractions of the vastus 
internus and the loss of support of the lacerated internal ligaments. 
Rest and strapping eventually cured the condition. If the patella 
remains out of place persistently, the surgeon should not hesitate to 
perform an open operation to replace it and suture the ruptured cap- 
sule. Old outward luxations are treated as described in the paragraph 
on other old luxations, each operation being adapted to fit the findings 
of the individual case. 

The prognosis of outward dislocation is variable. Unreduced cases 
may give some function. Popoff^ collected the results in 24 cases. 
There were 10 favorable results, 7 unknown, 5 bad results, and 2 deaths. 
In Vautrin's 7 cases reported in the same year there were 2 absolute 
cures. 

Rotatory Dislocations. — Some rotation of the leg bones is frequent 
in anterior and posterior luxations, as previously mentioned, because 
the laceration of ligaments which supported one side of the joint 
permits the causative force or gravity to rotate the leg. Pure rota- 
tory dislocation implies that the leg is not displaced either forward 
or backward on the femur, but turns upon an axis corresponding to 
the longitudinal axis of the leg. The rotation may therefore be of 
two different characters. First the tibia rotates on a long axis passing 
through the spines or the centre of the upper articular surface, each 
side of the surface turning away from the femur in opposite directions. 
One tuberosity moves forward, the other backward, the centre of the 
tibia retaining its normal axial relation to the femur. This luxation 
is the complete rotatory form. X very few cases have ever been 
reported. In these there was laceration of the lateral ligaments, and 
probably of the crucial ligaments, and the muscles about the joint 
also suffered tearing. In one case the internal tuberosity of the tibia 
came to lie directly forward, while the external tuberosity lay back- 
ward in the intercondylar notch. The semilunar cartilages may be 
loosened by this twisting, the insertions into the fibers of the internal 
lateral ligament pulling out the internal cartilage. Fracture of the 

> Th^HC de Lyon. 1904. 



SOO DISLOCATIONS OF THE KNEE 

tibial spine would also be expected. The biceps insertion may be 
torn from the fibula, or the other hamstring tendons may be wrapped 
around the condyles and prevent extension of the leg. 

The second type is incomplete rotatory luxation which is possible 
when the axial line on which the leg turns does not pass through the 
centre of the upper articular surface but does pass through one or the 
other tuberosity. This tuberosity remains in contact with the temur, 
and the other is turned away from its respective condyle, lying tmally 
either in front of or behind it. These incomplete rotations are found 
frequently in fractures through the tibial tuberosity and may also 
complicate anterior and posterior luxations of the knee. 

Reduction in all reported cases has been easily accomplished. 
Traction, or flexion and traction, combined with direct pressure over 
the upper end of the tibia has been the satisfactory means ot treat- 
ment If there is a tendency for the leg to fall backward or into any 
abnormal position, it should be held in straight extension by mechan- 
ical means and a plaster encasement applied. The joint must be given 
prolonged rest that the ligaments may obtain strength for weight- 
bearing Some partial disability follows all cases, and the patient 
must be cautioned against early and free use before the proper time 
for weight-bearing. If this injunction is not followed, the ligaments 
all become flabby, the joint becomes loose and tires easily. Disloca- 
tions of other types may follow and the patient has a permanent 
partial disability. . . , . , 

So-called subluxations of the knee follow traumatic sprains which 
involve nearly always the important internal lateral ligament. Ath- 
letes, children, and workers exposed to the conditions which result m 
abduction knee sprains suffer a weakening of the internal lateral 
ligament, which may be acute with the rupture of some of the hbers, 
or chronic with a gradual stretching. The leg is easily abducted and 
the joint seems unstable in lateral motion, so that a partial lateral 
luxation appears clinically. The fascia and fibers of the vastus mternus 
on the inner side of the patella may be lacerated. Reinforcement ot 
the tendons surrounding the knee-joint is lost, and the strain tails 
on the capsule and crucial ligaments. These traumatic injuries should 
not be overlooked by any surgeon because they ead to permanent 
weakness of the joint when they are not corrected and permitted to 
heal firmly. Football players, children, and others should have the 
joint firmly fixed in an adhesive strapping on the mside ot the knee 
and leg, or if the tearing is extensive enough to cause an ecchymosis, 
the leg should be immobilized three weeks in a plaster encasement. 
Some of these neglected sprains lead to an ultimate loosening ot the 
internal semilunar cartilage by the attrition which develops m the 
loosened joint and the traction of the attached fibers of mternal 
lateral ligament during the unusual loose excursion of the joint out- 
ward. Evansi reported 2 cases of knee subluxation. The associated 
lesion in his case was a detachment of the anterior end of the internal 
semilunar cartilage. 

1 Lancet, London, 1911, i, 224. 



DISLOCATIOX OF THE SEMILUXAR CARTILAGJES 80? 



DISLOCATION OF THE SEMILUNAR CARTILAGES. 

The reader is referred to the description of the Ugaments of the 
knee-joint in the chapter on Fracture of the Tibia. The two semilunar 
cartilages, wedge- and crescent-shaped, with the thick edge lying 
outward, each assist the opposite lateral ligament in limiting lateral 
movements of the leg. They are composed of fibrous tissue covered 
with hyaline cartilage and are often connected by a transverse liga- 
ment. On the outer border of the cartilages the capsule fibers merge 
into the fibers of the semilunars, forming the coronary ligaments. 
An additional function is possessed by the cartilages because of their 
movement with the tibia in flexion and extension, namely, they perform 
the function of a pad or shock absorber between the tibia and femur. 
Rotatory movements at the knee-joint, however, take place between 
the tibia and the cartilaginous disks, the latter remaining with the 
femur. This normal range of motion within the joint is very slight. 
A close attachment between the internal lateral ligament and the 
internal cartilage has been described by Griffiths/ who cut the internal 
ligament, and was able to obtain separation between the two bones 
at the knee when the leg was in extension. In a flexed position this 
separation was checked by the crucial ligaments. Consequently the 
greatest strain on the internal lateral ligament occurs when the foot 
is abducted, the knee is partly flexed, and the femur is rotated inward. 
These facts fully explain the mechanism of cartilage dislocation. 
Strain on the internal lateral ligament and the internal cartilage result 
when the leg is extended, when the foot is in abduction, and when 
the inertia of body weight as in a person getting off street cars or 
stepping off a height, gives an inward twist to the femur. Rupture 
of the internal lateral ligament, as in the cases of subluxation of the 
knee previously mentioned, does not affect the cartilage, if the tear 
takes place above the joint level. When the ligamentous tear is 
below the joint level, more rotation of the leg is permitted, and the 
cartilage follows the femur and is displaced from the tibia. Complete 
rupture of the coronary ligament fibers between the cartilage and 
ligament will permit the disc to be displaced inward toward the joint. 
If the twisting and abducting force separates the bones sufficiently, 
the cartilage slips inward, and as the bones spring back into place 
at the cessation of the trauma, the cartilage is caught and nipped so 
that the knee is painfully fixed. The force may tear or fracture 
the cartilage. Joint effusion follows, from irritation of the synovial 
membrane. 

Displaced or torn cartilage may be thickened, curled up, or thinned. 
Fibrous nodules develop in the injured disc, and loose bodies of car- 
tilage, fat, or organized blood-clot may also be present in the joint. As 
a rule the cartilage is displaced inward and acts as a mechanical wedge 
to fix the joint. In relatively few cases the cartilage is displaced out- 

1 British Med. Jour., 1900, ii, 1171. 



SOS DISLOCATIONS OF THE KNEE 

ward 1)\' joint rtt'usion or by the original trauma, and it may be pal- 
pable on the articular margin. Jones^ found in a series of over 400 
cases that the external cartilage was dislocated in 7 per cent. This 
fact is explained by the firmer fixation of the external cartilage by the 
joint ligament, and the normal line of force between femur and tibia 
which is extended through the inner side of the knee. The more 
intimate connection of the internal lateral ligament with the anchor- 
ing of the internal cartilage, and the more frequent abducted position 
of the foot which produces the strains following upon outward rotation 
also have bearing on the less frequent displacement of the external 
cartilage. 

After a primary luxation the condition tends to become habitual 
and recurs in unguarded movements when the leg is turned suddenly. 
Slight turns when the knee is flexed, as in the act of going downstairs, 
may be sufficient to cause many recurrences, and the patient finds 
use of the joint correspondingly restricted. 

Symptoms. — In a primary injury the twisting strain is generally 
a powerful one, occurring commonly in athletes. There is a sudden 
sickening pain in the knee, which becomes fixed in a flexed position 
and cannot be extended. According to Jones, actual locking of the 
joint is present in only one-half of the cases. By holding the leg in 
flexion the patient may be able to walk on his toes to a place of assis- 
tance. Local tenderness to pressure exists on the inner aspect of the 
joint, and a palpable separation between the tibia and femur may 
be felt by the surgeon when the leg is extended to the limit of the 
locked position. A prompt reduction may lead to little joint effusion. 
When the cartilage remains displaced a synovitis ensues. The joint is 
painful for several days, even if reduction is performed immediately, 
and there is tenderness to pressure on the internal ligament. Early 
use of the irritated joint before the cartilage has healed in position 
is practically always followed by repeated attacks of dislocation at 
intervals of days or months. Repeated effusions further weaken the 
capsular structure, the cartilage undergoes retrogressive changes, and 
the luxation becomes an habitual one. Each time the disc remains 
out of position until it is reduced by manipulation, either by the patient 
himself or the surgeon. Constant irritation of disc luxation may lead 
to tuberculous joint or to serious osteo-arthritic changes.^ 

Diagnosis. — Differential diagnosis includes joint mice, or foreign 
bodies of any origin, which interfere with perfect freedom of motion. 
Joint lipomata, synovial fringes, and hypertrophied villi cause con- 
fusion in diagnosis. The history of acute locking foflowed by pain and 
joint effusion, with subsequent similar attacks, is clinically all that is 
needed for diagnosis. Mistakes have been made by the most eminent 
surgeons, but a mechanical derangement of the knee-joint which 
indicates operation is nearly always an affair of the cartilages; when 
it is not, the necessary operation exposes different pathology, but the 

1 Ann. of Surg., December, 1909. 

2 Jones, Loc. cit. ; Lane, Clin. Jour., London, 1900, xvi, 103. 



DISLOCATIOX OF THE SEMILUNAR CARTILAGES 809 

lesion is corrected. Roentii'eiiogram is a very unsatisfactory aid, as 
the disc rarely throws a distinct shadow. The picture may aid in 
differentiation, however, by exposing other lesions of foreign bodies 
and fracture of tibial spines and other portions of the bones. 

Treatment. — Displacement of the cartilage must be reduced, as trau- 
matic displacement of any luxated portion of bony framework must 
be, before function can be completely restored. Intimate relation- 
ship between the internal lateral ligament and the disc, a tendency 
to recurrence from slight causes, and the great importance of the 
integrity of the internal lateral ligament to the normal knee-joint, 
establish the following rules for treatment: 

1. The primary reduction must be complete. 

2. The cartilage must be given absolute rest until its attachments 
have united. 

3. The internal lateral ligament must be guarded against strains 
of any kind until full strength is restored. 

4. The additional injunction is made against arthrotomy for 
primary dislocation — unless reduction is impossible by manipulation 
and the knee is in a locked or functionless position. 

Reduction. — Xo anesthesia is necessary in most cases. The patient 
is placed on a couch. Any method of manipulation which secures 
full extension of the leg is satisfactory, because that position means 
that the cartilage has been completely reduced. A customary proce- 
dure is first flexion of the knee with the surgeon's wrist in the popliteal 
space. When maximum flexion is obtained, the leg is rotated away 
from the injured side, that is, outward when the internal cartilage is 
displaced, and then quickly and fully extended. If there is any 
obstacle to full voluntary extension of the leg, the reduction is not 
perfect. Several attempts may be necessary before the patient can 
extend the leg or the knee-joint feels normal. A small proportion of 
cases will be irreducible — these are transferred into the habitual class 
at once, or are subjected to operation for removal of the disc. Refusal 
of operation demands palliative treatment. A longitudinal pad may 
be worn strapped around the knee, making pressure on the inner side 
of the joint, or an outside iron with a joint at the knee which inhibits 
rotation of the foot beyond a narrow angle may be worn. Elastic 
knee-caps and a raising of the inner side of the sole and heel of the 
shoe are also helpful. The patient leads a life of guarded use of the 
joint, and his activities are correspondingly restricted. Recurrence 
follows recurrence until the patient learns to make reductions himself. 
After the cartilage slips out, he sits on the ground and uses his well 
knee as a fulcrum in the popliteal space of the injured joint, rocking 
and alternately flexing and extending the leg in as much outward 
rotation as possible until reduction occurs. 

Adherence to the rules outlined for treatment will guard against 
recurrence. After reduction the cartilage must be secturely held in 
its fixed position. This fixation can be maintained only when the leg 
i> completely extended, all rotatory and lateral movements of the 



810 DISLOCATIONS OF THE KNEE 

joint being interdicted. Rest in bed with the leg on a posterior padded 
sphnt is insisted upon until the joint effusion subsides, and then a 
plaster encasement is applied over the thigh and leg. Four to six weeks' 
immobilization favors firm adherence of the cartilage, and use is then 
cautiously permitted after the patient has been warned to put no 
strain on the internal lateral ligament. He is instructed to walk with 
the toes turned in, and the shoe sole is raised on the inner side. 

Operative treatment should not be advised for primary luxation. 
Arthrotomy is indicated for repeated luxations, especially those which 
are followed by joint effusion, and in the cases of individuals to whom 
a sudden locking of the joint may be dangerous on account of occupa- 
tion or other activities. A sudden painful fixed position of the knee 
might cost the patient's life, if it overtook him at a moment when the 
movement was demanded to avoid threatening dangers. 

Operative treatment for removal of the loose or fractured cartilage 
is performed frequently and gives the only hope of complete cure. 
Mr. Robert Jones has performed over 500 arthrotomies on the knee 
with very few untoward results. A strict asepsis is necessary, and 
the operative technic employed in fractures is used. x4n angular 
incision two and a half or three inches long is made over the lateral 
aspect of the joint on the side affected while the knee hangs oveT the 
table edge. Deep retraction exposes the cartilage, which can be grasped 
by forceps and cut off. Only boiled instruments, of course, must be 
introduced. Attempts to suture the cartilage in place have been 
abandoned in surgery, the result following excision being eminently 
satisfactory. The joint is not manipulated during operation lest there 
be air suction, and the opening is closed layer by layer with catgut 
stitches. If an unfortunate infection in the skin or superficial layers 
follows, it rarely passes into the joint. In the hands of experts 
infection of the knee is almost unknown. 

DISLOCATION OF THE FIBULA. 

The fibula may be dislocated at either end, the luxations at the 
lower end usually being a complication of fracture considered under 
the heading of Ankle Fractures. 

Dislocations of the upper end of the fibula are caused by direct 
violence from kicks, or blows, indirect violence in connection with 
fractures of the bone in its lower portion, and muscular action of the 
biceps tendon. Golley^ reported a case. There are not more than 
30 cases in the literature. The head of the fibula may be displaced 
forward and outward, backward or upward, the direction depending 
on the cause. A flat surface on the tibia against which the fibula 
lies restrained by ligaments does not furnish great security, and if 
the ligaments are widely torn, the head of the bone may be movable 
in any direction forward to backward. I have seen one case caused 

' Am. Jour. Surg., June, 1907. 



DISLOCATIOX OF THE FIBULA 811 

by a kick in a football game. There was no fracture of the bone, but 
the head could be shoved aroinid into several positions just beneath 
the skin. 

A case of traumatic dislocation of the fibula at the upper end was 
reported by Klose.^ The patient jumped or fell on the inner border 
of the foot and felt pain and noticed swelling over the head of the 
bone when he tried to walk. There was pain on pressure at that site 
and on flexion of the knee beyond an angle of SO degrees. Xo fracture 
of the fibula nor nerve complication was present. Reduction was 
made by dorsal flexion of the foot, flexion of the leg, and direct press- 
ure on the head of the fibula. The cause was supposed to be muscular 
contraction of the common extensors of the toes, the extensor of the 
great toe and the long peroneus. 

A direct blow on the back of the head of the bone and a fall on the 
extended and inverted foot may act as causes, either forcing the head 
forward by direct violence or dragging it out of place by leverage from 
muscle action on the lower part of the shaft- The fibular head assumes 
a prominent position forward and outward, and there is pain on press- 
ure over it, or when weight-bearing is attempted. Traction on the 
biceps tendon may cause pain and abnormal movement of the head 
of the fibula. 

Diagnosis. — Diagnosis is not difficult but is often overlooked. A 
roentgenogram may fail to show any deformity. The anteroposterior 
view should be made from directly in front backward, and both legs 
should be exposed for comparison. 

Reduction by direct pressure of the surgeon's fingers is not difficult, 
but the bone tends to slip out at once on account of the poor reten- 
tion by the torn ligaments. After reduction the leg should be partly 
flexed that the biceps tendon may relax, a soft pad should be placed 
against the head of the bone, and a plaster-of-Paris encasement 
applied in that position. Fixation in the dressing must last four to 
six weeks, and use is then possible — the position of the head of the 
bone being strengthened by adhesive-plaster bands. 

Backward dislocations may also be caused by direct violence or 
wrenches at the knee which tear the external lateral and tibiofibular 
ligament and allow the biceps to pull the head of the bone backward. 
The peroneal nerve may be involved. Palpation of the head of the 
bone determines its position backward; there is tenderness on press- 
ure and pain on walking. Reduction is easy, and the same type of 
treatment is needed as in forward luxation. The prognosis as to func- 
tion is excellent. Cases of either type which resist reduction or will 
not remain reduced can be held in place against the tibia })y a nail 
inserted through a small skin opening. 

Upward dislocations belong to the exaggerated type of luxation. 
They usually accompany fracture of the fibula or of both bones of the 
leg in which the fibular head has been torn from its ligamentous 

' Deutsrh. Militiirarztl. Zt.srhr., Horlin, 19i:^. xlii. 911. 



S12 DISLOCATIONS OF THE KNEE 

attac'hiHonts and shoved upward by the force acting. An open wound 
may be present. Hechiction of the ankle or leg fracture usually brings 
the upper end of the fibula down into position. If it does not, the 
ankle may be forcibly extended and the fibula forced down by digital 
pressiuT on its head. 

Dislocations of the Lower End of the Fibula. — Pure luxation without 
fracture is extremely rare. Separation of the fibula from the tibia 
involves rupture not only of the ankle ligaments but of the tibiofibular 
interosseous ligament for some distance upward. A lateral or upward 
displacement of the bone takes place and the ankle is thickened and 
shortened by the pushing upward of the talus between the two leg 
bones. There may be a concomitant upward dislocation of the upper 
end of the fibula. In a few recorded cases the external malleolus has 
been displaced backward without fracture. 

Diagnosis. — Diagnosis is not difficult, because the malleoli lie sub- 
cutaneously and can be completely palpated. Pain is present and loss 
of function. Crepitus may be felt on manipulation of the foot from 
rubbing of the talus. The roentgenogram shows the diastasis between 
the two leg bones. Exposure of the whole leg is necessary that fracture 
of the upper part of the shaft may be ruled out. 

Treatment. — Reduction is made by direct traction on the foot and 
pressure on the fibula. If that manipulation fails, the foot can be 
strongly adducted during traction, and the external malleolus can 
be pressed down into position. The after-treatment consists of a 
prolonged immobilization in a plaster splint or encasement like that 
advised for ankle fractures. No use should be made of the ankle 
which causes pain or brings stress on the healing ligaments to stretch 
them. 



CHAPTER XXVII. 
FRACTURES OF THE CALCANEUS (OS C ALOIS). 

The calcaneus in the heel transmits a large part of the body 
weight to the ground and in addition acts as a lever to the calf muscles. 
Its shape is irregularly cuboid, and the long axis is not directed exactly 
forward in a straight line but is forward and lateral. This bone of 
all the tarsal group has two distinct centres of ossification, that for 
the posterior extremity appearing at the tenth year, uniting with the 
rest of the bone soon after the sixteenth year. In this area is attached 
the tendocalcaneus (Achilles). It has practical importance as applied 
to fractures (see Fig. 609). 

Steindler^ has made a careful study of the architecture of the tarsus, 
especially of the calcaneus, and Fig. 610 is an adaptation of the 
Hoaglund schema of the arch of the os calcis given by him. This 
bone appears to afford a good example of the inner construction of 
bones as influenced by their static conditions, in accordance with 
Wolff's ideas, which have been generally adopted. The Hoaglund 
construction of the calcaneus assumes that there are two trabecular 
systems.^ These are (1) the radiar system as represented by the 
three sets of lines 1, 2, and 3, w^hich lines of force converge tow^ard the 
centre of the bone and correspond to the distribution of compressional 
violence, and (2) the arcuar traction lamellae, 4, 5, and 6, which repre- 
sent the pull of the gastrocnemius and plantar musculature. 

Occurrence. — In the Cook County Hospital records of 10,702 cases 
I find 92 instances of fracture of this bone, or 0.86 per cent. Other 
collections cited bv Brind'^ are as follows: 





Fiartureg. 


Calcaneus. 


Per cent. 


Billroth 


. . . 663 


7 


1.1 


Tietze 


, . . 17,000 


206 


1.2 


Drenke (Charite) 


. . . 1,845 


29 


1.3 


Lemmen (Koln) . 


. 3,554 


65 


l.S 


Brind (15 jears) 


. . . 3,460 


63 


1.82 



Avulsion fracture was the first known type, being described by 
(^larenglot in 1720. The next description of calcaneus fractures by 
Malgaigne, in 1843, gave two varieties: first, compression fractures; 
second, avulsion fractures caused by muscular or tendinous pull. 
Other classifications, as Golebrewski's five forms and Iloff'a and 

' .Jour. Am. Orthop. A.s.sn., 1013. 

- Radiofrrafi.ska StudieroeferSpongio.seus furiftionella Structur i oalfarieus. Akadoniik 
.\fhandling, Upsala, 1903. 

' Arch. f. kiin. Chir., Berlin, Bd. cv, Heft III. S. 603. 



814 



FRACTURES OF THE CALCANEUS 



TARSUS. 

One centre for each hone, 
except calcaneus 



OUTER FOUR METATARSALS. 

Two centres for each bone 
One for body 
One for head 



PHALANGES. 

Two centres for each bone : 
One for body 
One for metatarsal 
extremity 



\%'^' ^ tj~^ Appears 10th year ; 
• ^/^^>"~ ' \ unites after puberty 

All ' 




r—-^^^ Appears ^rd year 
^^^ ) Unite 18th-20th year 

p Appears 7th week 



App. 6-7th yr. 
Unite 17-18 yr. \ 

App. 2-4 mo. -CI- 
App. eth yr. ^ 
Unite 17-18 yr. { "TT j| 

App. 1th wk. -^J>t 

Fig. 609.— Plan of ossification of the foot. (Gray.) 




Fig. 610. — Adaptation 



4 1^. 

of the Hoaglund scheme of the trabecular systems in the calcaneus. 



AVULSIOX FRACTURES 



815 



Schmidt's four forms, are now complete enough to cover our knowl- 
edge smce the use of the Roentgen rays. These are: 

1. Avulsion fractures. 

2. Isolated fractures of the sustentaculum tali. 

3. Isolated fractures of the trochlear process (peroneal tubercle). 

4. Compression fracture of the whole bone. 

Avulsion Fractures. — Avulsion fractures of true character are rare 
and exist with all degrees of separation of the fragments from slight 
cracks or sprain fractures to complete avulsion and separation of the 
torn-out piece (Fig. 611). This class is confined to those fractures 
caused by muscular action as in a person making a misstep off a small 
elevation, or jumping, or as in one case observed by me when a man's 
weight was suddenly increased by pressure as he squatted on his 




Fig. Gil. 



Avulsion fracture of the calcaneus. Fragment drawn upward by the 
calcaneus tendon. 



feet, supporting his weight on the buttocks which rested on the heel. 
The sudden increase of pressure on the calcaneus tendon and the 
violent contraction of the calf muscles pulled out the shell of the 
posterior part of the os calcis. Many such separations even in adults 
take place along the lines of the epiphysis. Fractures caused by press- 
ure of the body weight downward with a line of vertical fracture 
resulting and the posterior fragment pulled up by the calcaneus tendon 
are not true avulsion fractures. In the 63 cases collected by Brind' 
only one was due to an avulsion. 

Symptoms and Diagnosis. — There is pain and broadening in the heel, 
loss of function in the foot and a filling in of the hollows about the 
ankle and heel. If the foot is hyperflexed dorsally when the kne-e is 
extended, separation may be seen. Crepitus is frequent. A loose 



Loo. cit. 



sm 



FRACTURES OF THE CALCANEUS 



fragment may be both seen and felt drawn up behind the malleolus. 
Hoffa's sign is valuable in diagnosis. It consists in finding that the 
calcaneus tendon on the injured side is less taut than that on the other 
side when the two are compared with the legs in similar position. 

Treatment. — The treatment consists in the foot being placed in a 
plaster-of-Paris shoe in a position of complete flexion (plantar). In 
some instances flexion of the knee permits added relaxation, and 
this position must be maintained by a cast which extends onto the 
thigh. Five or six weeks in this position result in prompt callus for- 
mation and bony union, and function quickly returns. Operative 
procedure may be required. The simplest consists in a tenotomy of 




Fig. 612. — A less extensive avulsion fracture with displacement upward. 



the calcaneus tendon to permit the avulsed fragment to be replaced. 
An open operation may be performed and this fragment reduced into 
position and nailed, screwed, or wired on.^ B orchard obtained a good 
result in 2 cases by wiring, and Neuschafer^ fastened 1 by strong 
catgut with the result that in three and a half months the patient 
could readily walk upstairs. Tritze^ believes that open operation is 
the treatment of choice if there is much displacement, and this is 
common practice; cigar-box nails or small screws hold admirably 
(Figs. 612 and 613). 

^ Gussenbauer, Prag. Med. Wchnschr., 1888, No. 3. 

2 Deutsch. Ztschr. f. Chir., 1«99, Bd. 1, H. 5 and 6. 

3 Arch. f. Orthop., Bd. vi, H. 4. 



ISOLATED FRACTURE OF THE SUSTENTACULUM TALI 817 

Isolated Fracture of the Sustentaculum Tali. — These fractures, 
which are rare, and were first reported by Abel/ who beheved they 
were frequently mistaken for Pott's fractures. They are caused by 
extreme and forcible inversion of the foot, which later when put into 
use becomes pronated. 

Diagnosis. — Diagnostic signs are: (1) Localized point of extreme 
tenderness over the sustentaculum; (2) slight displacement of the 
OS calcis forward; (3) the foot in a position of forced abduction; (4) 
valgus position assumed by the foot in walking. An interesting 




Fig. 013. — Operative repair of the preceding. Note that the foot is encased in plaster 
in extension to relax the calcaneus tendon. 

example of this fracture has been recorded by Skillern,- in which a 
man fell ten feet and the skiagram showed an impaction fracture of 
the sustentaculum which was driven into the calcaneus. 

Treatment. — Treatment consists in immobilizing of the foot in a 
plaster shoe in slight inversion to permit reunion of the fragments. 
The cases usually obtain bony union in a short time but may "result in 
permanent deformity and non-union. The metal insole may help 
strengthen the foot if it does not cause pain by pressure. If a loose 

1 Arch. f. klin. Chir., B. xii, Heft 2, 396. 

2 Ann. of Surg., Ivii, 290. 



SlcS FRACTURES OF THE CALCANEUS 

fragment of bone exists, it may require removal on account of press- 
ure pain or interference with tendon action.^ 

Fractures of the Trochlear Process. — These injuries are about as 
frequent as those of the sustentacuhim and are due to direct violence, 
as the calcaneofibular ligament is not inserted in this process directly 
but behind it, and the pull on the ligament does not affect this bone 
point. There is always great pain, and the patient is unable to walk, 
and yet the foot does not appear abnormal in any way. Under the 
external malleolus swelling may appear. Brind'^ reports a case where 
at a point 2 cm. behind the external malleolus there was found a piece 
of bone 2 cm. long by 1 cm. wide which lay parallel to the foot, w^as 
freely movable, and gave crepitus. The prognosis is good, and treat- 
ment consists in suflBcient immobilization to permit bony union. 
Epiphyseal separations of the calcaneus occur between the ages of 
ten and sixteen years and in boys more often than in girls on account 
of their activity. They are treated as the fractures of the process 
above. 

Compression Fractures. — This class composes at least 90 per cent, 
of all calcaneus fractures. They are far more common in men than 
women. Men in such occupation as plasterers, carpenters, steel 
structure workers, or others exposed to falls are liable to this injury. 
Most of the fractures occur in the third and fourth decade, but they 
have been found in children, or in the aged as late as seventy years. 
The lines of fracture are of many descriptions, from a faint crack 
that is difficult to decipher in a good dry roentgenogram to great 
comminution and mashing of the bone. 

Weight-bearing bones which withstand much pressure assume a 
spongy form with the many truss-like trabeculse crossing at various 
angles sustained by extra strong bands in the calcaneus as mentioned 
above. This is because the calcaneus with the cuboid and two outer 
metatarsals form the outer arch of the foot which sustains most of 
the body weight, and we find the compacta of the heel bone is but 
a shell, especially on the lateral and inferior surfaces (Fig. 614). The 
spongy character of the bone endows it with considerable elasticity, 
which preserves it from being crushed in falls on the foot by the break- 
ing up of the lines of force exerted by the compression inertia. Com- 
pression may also be applied to this bone in injuries which result 
from force applied laterally to the leg when the foot and knee are fixed. 
Experiments to test the compression resistance of this bone have 
been made by Schmidt,^ who found that a crunching could be caused 
by a force equivalent to 150 to 950 kilograms and that a cracking 
break through the bone necessitated a force of 550 to 2000 kg. These 
fractures are due to falls from a height onto the foot or a heavy, 
violence applied directly to the sole (Fig. 615). Cabot and Binney^ 
studied 111 cases of fracture of the calcaneus and talus which were 

' Ossenkop, Frakturen cies Calcaneus, Inaug. Diss., Wiirzburg, 1892. 
2 Loc. cit. 3 Arch. f. klin. Chir., Bd. li, H. 2. 

'Ann. of Surg., xlv, 50. 



COMPRESSIOX FRACTURES 



819 



admitted to the ^Massachusetts General Hospital in fifteen years. 
They found a surprising frequency of these tarsal fractures, S3 occurring 




Fig. 614. — A combination of compressional and avulsion violence, incomplete fracture 

of the calcaneus. 




Fig. 615. — Ordinary compres.sion fracture without much separation. No crepitus 
obtained. This type is often unrecognized and leads to disaVnlity. 



in the same period of time that 204 Pott's fractures and 39() femur 
fractures were admitted. In 03 of the 83 ca.ses mentioned the cause 
was given 59 times as fall from a height. 



820 



FRACTURES OF THE CALCANEUS 



Symptoms and Diagnosis. — Considering the great force needed to 
cause these fractures we expect definite evidence of bone injury. 
There is pain in the entire hollow of the foot and heel. The foot is 
swollen and often ecchymotic, the contour of the ankle-joint is lost, 
and the outer arch seems flat if the bone has been comminuted. Pas- 
sive motions of the foot are painful, the heel is broadened, and the 
foot rests deeper down — that is, the points of the malleoli seem nearer 
the ground when the patient, with both feet bared, stands on a table 
near the level of the observer's eyes (Figs. 616 and 617). Pressure 
over the bone may elicit crepitus and is always very painful. In old 
cases there is some atrophy of the leg muscles, probably from disuse, 
with increased reflexes in the leg with slight ankle-clonus. The patient 




Fig. 616. — Compression fracture with separation. Crepitus easily obtained. 

cannot walk and the heel remains swollen and painful; in fact the 
stubbornness of the symptoms is characteristic. The other foot bones 
are also injured in a small percentage of cases only. When the violence 
is very severe, its continuation may drive a fragment of the bone out 
through the sole of each foot. Bilateral fractures are frequent.^ Many 
cases remain undiagnosed. Ehret^ found that of 2016 patients, 47, 
or 2.3 per cent., had suffered fracture of the calcaneus. There were 
30 cases involving the left foot, 3 the right foot, and 4 both feet. Only 
3 of these 47 cases were correctly diagnosed. Seventeen old fractures of 
the tarsus were reported by Ely,^ 76 per cent, of which were improperly 
diagnosed. Fifteen cases were in men and 1 each in a boy and a woman. 



^ Voeckler, Deutsch. Ztschr. f. Chir., Bd. Ixxxii; Mertens, Arch. f. klin. Chir., 1901, 
Bd. Ixiv. 

2 Arch. f. Unfallheilk., 1896, i, 359. ^ Ann, of Surg., xlv. 69. 



COMPRESSION FRACTURES 



821 



All had to take to bed, and the disability in the fractures of the talus 
was much greater than in those of the calcaneus. The gait after use 
is attempted is characteristic, because the patient holds the foot 
immo\'able and always walks on the same point of the sole to avoid 
pressure pain. 

While the prognosis as to life is excellent, that in regard to function 
of the foot should be guarded, as many cases result in partial disability 
from painful walking, flat-foot or an acquired club-foot, or painful 
talocrural joint. These conditions are of prime importance in the 
working classes and should receive more attention from those treating 
these injuries. The disability is also enhanced by the muscle changes 




Fig. 617. — Compression fracture with separation of distinct^fragments. 

subsequent to the pain and the loss of support to the outer arch 
given by the calcaneus, as described above. Bahr^ reported 13 cases 
of calcaneus injury, 6 of which resulted in bad flat-foot and 1 in club- 
foot. Schmidt,^ in 14 cases, had 5 flat-feet and 3 club-feet result. 
Adolescents have a better prognosis than adults or alcoholics.^ 

Probably no foot returns to a normal condition after complete 
fracture of the os calcis. Cabot and Binney found no case with a 
normal foot in their series. The prognosis is fair to good in most 
cases, liesults are called good when a foot is painless and useful 
unless excessive work is demanded of it. Results are called fair in 

' Arch. f. Orthop., 1903, Bd. i, H. 1. ^ j^^f. Ht. 

3 Lemmen, Die Briiche des Fersenbeins, Diss. Iif)nn., 1001. 



822 FRACTURES OF THE CALCANEUS 

those cases whieli are able to return to their former occupation with 
some disability which is alleviated by pads or plates worn inside the 
shoe, earning capacity being but slightly impaired. Results are called 
bad when there is marked disability and greatly lessened earning power. 

Twenty-six cases of fracture of the calcaneus were examined by 
Cabot and Binney more than a year after injury. The results were: 
Good, 13, or 50 per cent.; fair, 10, or 38 per cent.; bad, 3, or 12 per 
cent. 

Five cases of comminuted fracture showed not one good result, but 
had 4 fair and 1 bad termination. The disability in 20 cases was known. 
In 14 cases it was not more than six months and a year, and in 2 it 
was one or two years, giving an average well over six months. 

Treatment. — Many authors believe that slight fracture, unrecognized, 
does better if untreated; that is, the patient gets about with a shoe 
on and stands the pain until it wears off. If the line of fracture tends 
to spread or pain prohibits this form of non-treatment, the foot should 
be immobilized in a plaster shoe, probably best in a position of plantar 
flexion to relax the calf muscles. Strohmeyer, in his Handbuch der 
Chirugie, suggests that there is little to do but reduce the swelling. 
Our practice is to put the patient to bed with ice on the foot until 
the swelling has subsided, and then by lateral pressure and manipu- 
lation place the fragments in the best position to be obtained and 
apply a well-fitting plaster shoe which extends at least half-way up 
the leg. After four weeks this is removed and massage is given, but 
no weight is borne on the foot for two months or more after injury 
if the bone has been comminuted or the fragments much displaced. 
No walking should be countenanced until pain has gone. 

For avoidance of the flat-foot, treatment with Konig's apparatus 
can be used. This is a cross-bow shaped piece of iron with an adjust- 
able foot-piece which is held by a threaded bolt and by means of 
which the fragments can be held in place. Operative treatment to 
nail displaced or loosened fragments is good practice. The posterior 
fragment can be pulled forward and downward by continuous trac- 
tion applied to a nail passed through it, as in Steinmann's method. 
Such treatment was described by Cotton and Wilson,^ in which the 
steel pin was not passed through the fragment but between the bone 
and the insertion of the calcaneus tendon. Later Gelinsky,^ at the 
Charite in Berlin, described this as a new method with his modifica- 
tion. Under ether anesthesia he does a tenotomy of the calcaneus 
tendon and between its insertion and the bone passes a strong silver 
wire. A thin piece of board is placed along the sole of the foot and a 
rubber sponge is placed in the hollow of the sole, the forepart of the 
foot being tightly strapped to the board, and the ends of the silver 
wire are connected to an extension of ten to fifteen pounds. After 
fourteen days the board and sponge are removed and a plaster shoe 

1 Boston Med. and Surg. Jour., October 29, 1908. 

2 Centralbl. f. Chir., 1913, Heft 21. 



FRACTURES OF TALVS AXD OTHEn FOOT BOA'ES 9>^^ 

is applied, following which the patient becomes ambulatory. The 
cast is removed in four weeks. 

♦ After-care consists in massage, hot baths, steaming and electric 
treatment to strengthen the muscles and foot-joint and to ward off 
their stift'ness. Full treatment takes from three to six months, and 
the insole and special shoe advised in Pott's fractures should be worn. 
Tritze says that 24 out of his 70 patients recovered good function, 
and this is equivalent to good earning power. The cases should be 
followed faithfully until the final result is obtained. In Brind's series 
S7 patients, or 43 per cent., obtained 25 per cent, or less use of the 
foot, whereas 107 patients obtained 30 per cent, or more use. 

FRACTURES OF THE TALUS (ASTRAGALUS) AND OTHER 

FOOT BONES. 

The talus is the second largest ankle bone and occupies the key- 
stone position in the ankle arch, resting on the calcaneus below, lying 
in the mortise between the two leg bones, and resting against the 
navicular bone in front. Its division into a head, which points forward, 
a neck, and a body which forms the largest part, is of interest in 
fracture. It has also on the posterior surface of the body a prominent 
tubercle of varying size to which the posterior talofibular ligament is 
attached. This is the posterior process; it may lie separately from 
the talus. This process is of importance in fractures, because its 
presence is often misunderstood, and the separate piece of bone 
appearing in the roentgenogram is diagnosed as a fracture. When so 
separated it is called the os trigonum. 

Because there are several of these supernumerary bones in the 
foot, knowledge of their presence should be wide-spread in order that 
errors in diagnosis and medicolegal testimony may be avoided. A 
very complete atlas of them has been prepared by Dwight^ from dis- 
section of cadavers, and by the use of the Roentgen rays their presence 
is verified and their connection with symptoms of pain following 
trauma can be proved. Geist^ made a study of 100 normal individuals 
to determine the frequency of accessory bones which he found in 
thirty persons as follows, his results corresponding very closely to 
Dwight's and Pfitzner's figures: Os trigonum, 8 per cent.; os peron- 
eale, 7 per cent.; os tibiale externum, 14 per cent.; os vesalii, 1 per 
cent.; accessory calcis, 2 per cent.; os intermetatarsum, 2 per cent.; 
os intercuneiforme, 1 to 2 per cent. (Figs. 618 and 619). 

Some of these may have separate centres of ossification; others 
are freed from the parent bone and become sesamoid in character. 
All the ankle tendons pass over the surface of the tahis, which corre- 
sponds to a block and pulley in function, because most of these tendons 
have grooves in the bone surface in which they play. These tendons 
cause the motions of flexion and extension of the ankle, and at the 

' Variations of the Bones of the Hand and Ff)ot, HK)7. 
2 Tr. Am. Orthop. Assn., June, 1914, xii, No. li. 



824 



FRACTURES OF THE CALCANEUS 



same time the talus occupies the position of transformer of direct 
motion in the ankle, acting according to Cotton like a worm gear.^ 




Fig. 618. — Os tibiale externum — compare with picture of fracture of the processus 
posticus tali. This patient gave a history of injury and the sesamoid bone may have 
developed after fracture. 




Fig. 619. — Os peroneale. 
Am. Surg. Jour., xxviii, No. 1, p. 32. 



FRACTURES OF TALUS AXD OTHER FOOT BOXES 



825 



It has the power of rotatory motion, of pronation and supination which 
occurs noAvhere else in the body except in this tarsal joint. ^ 

Fractures of this bone are divided into those of the head, neck, cracks 
or severe fractures through the body and of the posterior process 
(Fig. 620). Dislocations and fractures commonly occur together (Fig. 
621). In the collection of fractures made by me at the Cook County 
Hospital this bone was broken in 14 instances. Falls from a height 
cause crushing of the bone between the tibia and the os calcis beneath, 
and the heel bone or either of the malleoli may suffer damage at the 
same time according to the position of the foot and the point of impact. 




Fig. 



620. — Fracture through the weak part 
of the talus. 



Fig. 621. — Fracture dislocation 
of the talus. Note that the larger 
fragment is displaced outward. 



The talus is fairly protected by its situation between the malleoli 
and by the crescentic contour of its upper surface. As a consequence 
the line of fracture varies greatly; the neck alone may break off, the 
whole bone may be split in its long axis, or it may have transverse 
and comminuted lines of separation with wide displacement and 
dislocation of the fragments. Cotton^ records a case of fall in which 
the individual sustained the impact on the ball of the foot on one 
side and the heel on the other with a resulting fracture of the neck 
of the talus and the os calcis respectively. Gaupp,^ in (il cases, 



' Lovett and Cotton, Tr. Am. Orthop. Assn., xi, 1899. 
2 .Joint Fractures and Dislocations. 
» Beitr. z. kiin. C'hir., 1904. 



820 FRACTURES OF THE CALCANEUS 

foiiiul that 45 were caused by falls, and Cabot and Binney/ in 35 
cases, found 21 caused by falls and 14 by direct violence. In transverse 
fractures following falls or jumps, the posterior half is displaced 
backward and generally lies just in front of the calcaneus tendon. 
The anterior portion may be displaced, but in many cases remains 
unmoved. The roentgenogram alone shows the pathology, and both 
feet should be exposed for comparison. Even then the evidence may 
be disappointing. 

Symptoms. — There is usually swelling of the ankle and much pain, 
especially when the foot is dorsiflexed, and if the fragments are com- 
minuted and separated, crepitus can be felt with this movement. 
The patient cannot bear weight. And in fracture of this bone alone 
the malleoli and os calcis are found on palpation to be intact. If 
injury to these latter parts complicates the case, diagnosis may be very 
difficult. Crepitus, in cracks or fracture with little separation or 
great effusion of blood, may be absent, so that the Roentgen-ray 
examination is desirable in all suspected cases. 

Diagnosis. — Diagnosis is made by the surgeon feeling crepitus and 
finding a normal calcaneus and malleoli, or by feeling the loose frag- 
ment of the head or body pushed out of place and appearing under 
the skin, when accompanied by the evidence of injury as given above. 
Simple cracks without displacement can only be suspected and must 
be verified by the Roentgen examination. 

If no displacement exists, the foot is placed in a fracture box, and 
swelling and pain are controlled by an ice-bag. When these subside, 
the foot is encased in a plaster shoe in a position at right angles to the 
leg and in direct line of weight-bearing through the ankle mortise 
without inversion or eversion. If there is no displacement of fragment, 
Ely advises placing the foot in strong dorsal flexion. Cabot and Binney^ 
examined 8 cases of fractured talus after a year's time. The results 
were good in 2 and bad in 6. The length of disability was known in 
9 of their cases. In 1 it was not in excess of six months, in 2 it was 
six months to a year, in 2 it was twelve to eighteen months, in 1 it 
was eighteen to twenty-four months and in 3 it was over two years. 

Where one fragment is displaced and the other is in situ the displaced 
portion should be removed; the fixed part may be safely left, and 
good movement with no shortening of the ankle results. If reduction 
is attempted, the skin must be watched for necrosis, because many 
cases become infected, and a persistent osteomyelitis disables the 
patient for a long time. If the bone is broken horizontally or severely 
comminuted, or part is driven down into the calcaneus, it should be 
completely removed by open operation at once. This can be done 
by a lateral angular or curved incision. Hutchinson and Lett,^ 
although in favor of operative treatment, do not believe in removing 
all of the bone. Unreduced fracture of the talus usually shows marked 
thickening about the external malleolus with much pain, probably 

^ Loc. cit. 2 Loc. cit. 

' Tr. Chir, Soc, London, xxxviii, 159. 



FRACTURES OF TALUS AXD OTHER FOOT BOXES 



827 



caiised by the low position of this malleohis. The tip may be aiiky- 
losed in calhis or have a false joint formed about it. 

Instances of fracture of the neck with dislocation of the head may 
be reduced by manipulation or by use of the Thomas wrench. Open 
operations for reduction of the fragments by simple reposition or 
nailing do not promise well. Ashhurst^ reports a case in which the 
head could be felt anteriorly beneath the skin in its normal position, 
while the posterior fragment lay beneath the calcaneus tendon with 
the foot in slight cavus. When the site was opened it was foiuid that 
the fragments were separated one and a half inches; so both were 




Fig. G22.— Fracture of the posterior process of the talus with accompanying break in 

the fibula. 

removed, the posterior fragment only after a tenotomy of the calcaneus 
tendon. A plaster encasement for six weeks gave a good result. Old 
cases with deformity can be treated by a metal ankle brace. Excision 
of the bone is reached ultimately in most instances. 

Fracture of the posterior process may accompany injury to the 
talus or calcaneus. Fig. 022 represents a fracture of this process with- 
out separation, and Fig. 023 a fracture of the process into two separate 
fragments. The patient had pain and some swelling and tenderness 



Ann. of Surg., Iv, 120. 



S28 



FRACTURES OF THE CALCANEUS 



on pressure over this area, but diagnosis was possible only by the 
Koentgen rays. A presumptive diagnosis can be made on localized 
tenderness, history of the fall, and pressure above the external part 
of the insertion of the calcaneus tendon. Doubtless this process may 




Fig. 623. — Uncomplicated comminuted fracture of the processus posticus. 

be fractured and, becoming separated from the talus, assume a sesa- 
moid appearance in the Roentgen picture. A short period of immob- 
ilization should overcome the symptoms, but if they persist after 




Fig. 624, — Usual sites of fracture in the navicular bone through the tuberosity and 

through the body. 

use of the foot is attempted, excision can be done. Lillienfeld^ records 
7 fractures of this process in 600 instances of fracture. Five were in con- 



Archiv f. klin. Chir., 1905-6, Ixxviii, 945. 



FRACTURES OF TALUS AXD OTHER FOOT BONES 



829 



junction with calcaneus fractures, the mechanism probably being a 
fall on the heel with the foot in a position of plantar flexion. This 
position jams the calcaneus against the process. 

Fracture of the Navicular Bone (Scaphoid). — This bone lies on the 
median side of the tarsus between the talus and the cuneiform bones. 
The plantar surface is rough for attachment of the tibialis posterior 
muscle, and the median surface presents a tuberosity in which part 
of this muscle is also inserted (Fig. 624). Routine examination of 
injured feet by the Roentgen rays demonstrates that this bone is occa- 
sionally injured. One collection of 22 cases was made by Finsterer.' 




Fig. 625. — Fracture of the tarsal navicular by direct violence. 

The })one is most frequently crushed between the talus and the cunei- 
forms, and though painful, may, even in the Roentgen picture, show 
little evidence of actual fracture except distortion in shape (Fig. 
625; . Rarely well-defined lines of separation appear, or two distinct 
fragments are shown. When violence from falls is received by the foot 
in forced plantar or dorsal flexion, the navicular bone lies in direct 
line of transmission and suffers injury. Twists accompanying mal- 
leolar fracture at the ankle may also cause the bone to suffer from 
transmission of force or the pull of the tibialis posterior tendon. 



Bcitriige z. klin. Chir., lix, 90. 



830 FRACTURES OF THE CALCANEUS 

Symptoms. — Symptoms in recent fracture are pain and swelling 
over the inner side of the tarsus, marked tenderness to pressure, and 
free ankle motion. Midtarsal movements, however, are painful and 
restricted, and the foot is held in slight e version. If the fragments 
are separated and displaced, they may form a painful protuberance 
on the inner side of the foot. Inversion of the foot is greatly limited. 
In old cases the tenderness over the bone may have largely worn off, 
but the lack of inversion is noticeable. Abadie^ reported a case of 
fracture of the head of the talus and the scaphoid by compression. 
There was much pain in the middle of the foot on palpation or efforts 
to walk, with an extensive ecchymosis. Roentgen-ray examination 
is the positive means of diagnosis. Methods of recognition of this 
fracture are detailed by Lange.^ 

Treatment. — ^Treatment in cases of dislocated fragment consists 
in strong abduction of the forepart of the foot and pressing of the 
fragment down into place. A plaster shoe is worn for three weeks. 
INIacausland^ reports two acute cases and concludes that this bone 
suffers fracture without involvement of the other tarsal bones. Because 
the navicular bone is in direct line of weight-bearing and interference 
with its function disturbs the whole static function of the limb, it is 
better in comminuted cases that the whole bone be excised subperios- 
teally and regeneration be awaited while the foot is kept at rest in 
inversion. The new bone fits the space perfectly and is protected 
by an arch support or adhesive-tape strapping for several weeks. 
Deutschlander^ says conservative treatment is useless, and Hoffmann^ 
recommends excision in old cases. 

The presence of the sesamoid os tibiale externum, in the tendon of 
the tibialis posterior, may cause errors in diagnosis of a small fragment 
broken off .^ 

Fractures of the Cuboid and Cuneiform Bones. — These bones may 
be broken by direct violence, and crushed feet examined carefully 
by the Roentgen rays show instances of comminution of one or more 
bones, frequently in connection with the metatarsals (Fig. 626). 
The dropping of heavy objects on the foot or direct blows from ham- 
mers or wagon wheels in runover accidents are the cause. Muscular 
action may cause a chipping off of a piece of the cuboid, as reported 
by Skillern.^ In this case the left foot was twisted, something was 
heard to crack, and a swelling immediately appeared at the tarso- 
metatarsal joint definitely localized at the anterior and external cor- 
ner of the cuboid. Positive diagnosis depends on the localized point 
of tenderness with swelling and is to be confirmed by the Roentgen 
examination. 



1 Rev. d'Orthop., 1911. 2 Lancet-Clinic, 1908, c, 395. 

3 Ann. of Surg., lii, 845. 

4 Verhandl. d. Deutsch. Gesellach. f. Chir., Berlin, 1907, P. 2, xxxvi, 90-100. 

5 Beitr. z. klin. Chir., Tiibingen, 1908, lix, 217. 

6 Nippold, Arch. f. Phys. Med. u. Med. Tech., Leipzig, 1908, iii, 312. 

7 Ann. of Surg., Ivii, 289. 



FRACTURES OF TALUS AXD OTHER FOOT BOXES 



831 



Treatment. — Treatment consists in strapping of the foot as in Skil- 
lern's case, in overabduction, or the apphcation of a heavy phintar 
plaster strip for a conple of weeks when the bones are comminnted. 
The attendant shonld recall again the possibility of sesamoid bones 
confnsing the pictnre and being mistaken for broken-oif fragments. 
The surface of the tuberosity of the cuboid has a facet on which the 
sesamoid in the peroneus longus tendon glides. Refer to description 
in Fractures of the Talus. 

Fractures of the Metatarsal Bones. — Metatarsal fractures, though 
relatively common, are often overlooked. They are most often found 
among laboring men, and are caused by direct violence, such as the 




Fig. 626. — Fracture of a cuneiform bone. 

dropping of burdens or heavy objects on the feet. Freight handlers, 
movers, and similar classes are liable to these injuries. On account 
of the character of the injury and the small amount of deformity a 
large percentage of the cases are not diagnosed. Indirect violence 
is also a cause, attention being first drawn to it by Mr. Robert Jones,^ 
who fractured his fifth metatarsal across the corner of the base while 
dancing. Many cases occur in the feet of soldiers or of youths when 
jumping or playing tennis. Twist of the foot may cause fracture 
of the fifth metatarsal, possibly by pull of the peroneus brevis muscle, 



Ann. of Surg., June, 1902. 



832 



FRACTURES OF THE CALCANEUS 



as reported by Wharton.^ Lahey^ watched for fractures of the tuber- 
osity and proximal end of the fifth metatarsal bone in the Boston 
City Hospital. In four months' search he found 7 cases (Fig. 627). 
Lillienfeld^ observed 5 cases in 600 fractures, and Miller^ reported 
2 cases. The fracture is not common and is often mistaken for a bruise. 
Three different types are found: (1) the plane of fracture passes trans- 
versely through the proximal end of the bone; (2) it passes through 
the base of the tuberosity; (3) it passes through the tip of the tuber- 
osity with or without separation. 

The mechanism of fracture can be explained by the fact that most 
cases occur in the act of dancing, jumping, or slipping off a small 




Fig, 627. — Multiple fractures of the metatarsals and phalanges caused by direct 
violence. Note the transverse fracture of the fifth metatarsal. 

height. One of my cases followed a man slipping off the curbstone 
as he started to cross the street. The foot is supinated and in plantar 
flexion. The proximal ends and tuberosity of the fifth metatarsal 
bones vary in size, as has been shown by Dwight. For the first type 
Lahey is inclined to favor a mechanism of pressure from the body 
weight directed through the cuboid when the foot is in the supinated 
position. This cuboid pressure is counteracted by the ligaments uniting 
the fourth and fifth metatarsal to the distal end and probably also 



1 Ann. of Surg., May, 1908, p. 824. 

2 Boston City Hosp. Med. and Surg. Reports, 16th series, p. 250. 

3 Arch. f. klin. Chir., Bd. Ixxviii, 929. "Ann. of Surg., March, 1915. 



FRACTURES OF TALUS AXD OTHER FOOT BONES 



833 



by the traction on the tuberosity and proximal end of the peroneus 
brevis. In the second type the cuboid pressure probably acts as the 
counter-force, the actual cause being the pull of the peroneus brevis. 
The third t^-pe is really a pulling out of the muscle insertion, with 
dragging of a fragment of bone which in this case is probably an 
epiphyseal separation. A statement is made in Dwight's atlas that 
this epiphysis appears in about 4 per cent, of the fifth metatarsal bones 
between the ages of fifteen and eighteen years. Diagnosis is made 
on the history of the position of the foot at the time of accident and 
in some cases on the feeling of something giving way on the side of 
the foot or on an audible snap. There is much local pain with swelling 
and ecch\Tnosis appearing later. In the first type crepitus may be 
demonstrated. 



r-^ 





Fig. 628.— Fracture through the 
heads of the first two metatarsals. 
The sesamoids of the great toe are 
unharmed. 



Fig. 



629. — Fracture at the base of the 
middle metatarsal. 



The treatment is the placing of the foot in a plaster encasement 
extending above the ankle. This is left on for two weeks, and the 
fragment unites readily, leaving no disturbance of function. One 
case of non-union has been recorded. If a fragment failed to unite 
it might be nailed on, or, if it caused pain, entirely removed. 

In study of' the roentgenogram the surgeon must differentiate frac- 
ture from the os vesalii, which may be a separate epiphysis or an 
extratarsal bone lying near the proximal external part of the tuberosity. 
Coues^ reports a traumatic case in which the os vesalii was mistaken 
for fracture of the fifth metatarsal. 

The metatarsal bones are so closely packed together and surrounded 



Boston Med. and Surg. Jour., dxx, No. 19. 



53 



s;u 



FRACTURES OF THE CALCANEUS 



by muscles and the heavy plantar tissues that displacement after 
fracture is not great unless several are broken at the same time (Figs. 
628 and 629). In this case lateral overriding takes place, and usually 
the distal fragment tends to angulate upward. Several bones may 
be broken simultaneously, rarely on the same level, more usually at 
different points. The line of fracture is commonly transverse or slightly 
oblique; sometimes comminution is present. I have observed three 
cases of epiphyseal separation in the metatarsals (see Fig. 633). 

Diagnosis. ^ — Diagnosis is a trifle uncertain when direct violence has 
been the cause. Swelling and pain in the whole forefoot obscure direct 
findings, and frequently two observers while admitting fracture of 
these bones will not agree on the ones involved. The first metatarsal 

on account of size and superficial position 
can be felt in its whole length, and crepitus 
or false motion can be felt when it has 
been broken. If each toe is taken and 
gently moved in extreme flexion and ex- 
tension, one may feel crepitus of the 
metatarsal connected with it, or there is 
evidenced severe pain when the toe of the 
broken bone is moved. It is sufficient to 
have the history of severe trauma, and to 
find a point of extreme tenderness in one 
or more of the bones by deep pressure, 
and to find pain in the foot when weight 
is borne on it. The base of the fifth 
metatarsal is frequently broken off, either 
obliquely or straight across, and a per- 
sistent point of tenderness or pain is 
sufficient for diagnosis. 

Infraction or crushing in of the head 
of the second metatarsal has been called 
a typical injury by Freiberg. ^ He reported 
6 cases, the majority occurring in young 
females following trauma in playing tennis 
or stubbing the toe. The symptoms are much like those of flat-foot, 
except that the tenderness is localized at the head of the second 
metatarsal bone, where, if of long standing, a thickening of the bone 
can be felt. It is usually unilateral, and the roentgenogram revealed 
in some of the cases small loose bodies free in the joint in addition 
to the jamming down of the head of the bone. In one case the bodies 
were removed by open operation. The mechanism is doubtless caused 
by the fact that the second metatarsal bone is longer than the first, 
and if the flexor power of the great and second toe is insufficient, for- 
cible unguarded impact of the second metatarsal against the ground 
causes it to be jammed down and broken. 




Fig. 630. — Fracture at the 
base of the second metatarsal. 
Indirect violence. 



1 Surg., Gynec. and Obst., xiv, 191. 



FRACTURES OF THE PHALANGES OF THE FOOT S:^,") 

These fractures are really impacted or egg-shell fractures of the 
metatarsal head. Skillern^ reports a case in which the lateral roent- 
genogram showed an oblique indentation, but no loose fragments. 

Treatment.^ — The treatment consists in the application of a pad to 
the sole of the foot behind the head of the second metatarsal to elevate 
the transverse arch and keep it from pressure in walking. 

Open fractures of the metatar^mls are serious injuries because of the 
lower resistance of the foot structures, the almost sure infection from 
dirty skin or the environment of the trauma, and the possibility of 
gangrene from impeded circulation. The fracture as such is ignored 
and attention is directed to the point of establishing free drainage 
and keeping the foot warm and aseptic. Through-and-through open- 
ings of the foot are indicated if pus forms. Closed fractures, if of one 
bone, require a plantar support of a heavy plaster splint, or if several 
bones are broken with much overriding it may be considered neces- 
sary to perform open operation with simple replacement through a 
small incision on the dorsum of the foot. A plaster shoe well padded 
under the sole is then indicated. ^Nlost trouble and subsequent pain 
comes from allowing weight -bearing too early. The soft callus yields, 
and becoming thickened by irritation, causes pain by pressure. Four 
to six weeks' rest of the foot followed by a felt pad under the sole or 
a metal insole after walking is started will avoid this trouble. Old 
cases with pain usually yield to rest and these measures. Once I 
have removed excessive callus in old fracture for relief of pressure 
pain. 

Infraction is treated likewise, unless the free bodies in the toe-joint 
grate and are painful, in which event Freiberg advises their removal 
by arthrotomy. 

FRACTURES OF THE PHALANGES OF THE FOOT. 

These fractures are caused by direct or indirect violence and may 
accompany metatarsal fractures. Lines of fracture are usually trans- 
verse, although comminution occurs, especially of the distal phalanx 
Fig. (331). I have had one case of longitudinal fracture splitting the 
distal phalanx into four fragments, the other phalanges remaining 
intact (see Fig. 632). As the phalanges arise from two centres of 
ossification one for the body and one for the base, joining about the 
eighteenth year, epiphyseal separation occurs. 1 have observed 
several of these, but find no reference to them in the literature (see 
Fig. 633). A large proportion of these fractures are open, and, as has 
been stated in the section on Metacarpal Fractures, infection and 
gangrene are common sequences. Especially is this true of the distal 
phalanx, which is })oorly nourished and lias no periosteum, so that it 
is wiser to remove it early and in entin^tx' if infection extends into 
tlie bone. An interesting impacted fracture of tlic distal |)liahiiix of 

' Ann. of Surg., Ixi, Xo. 3, p. -iTl. 



I 



836 



FRACTURES OF THE CALCANEUS 



the great toe was reported by Beasley.^ The toe was shortened and 
the phalanx was driven down on the one above Hke a thimble on a 
tinger end. A small capillary drain in the wound after this removal 





Fig. 631. — Fractures of the distal 
phalanges. A small corner broken off the 
second phalanx of the great toe. 



Fig. 632. — Longitudinal splitting 
of the distal phalanx of the great toe. 



leads to almost primary union of the opening and a greatly shortened 
disability. Infections arising in the toes are often prolonged and 
lead to serious consequences. All open fractures of them should be 




Fig. 633. — Epiphyseal separation of the metatarsals and phalanges. 

energetically treated, as indicated in the chapter on Treatment, and 
antitetanic serum should be given. 



Railway Surg. Jour., February, 19X5. 



DISLOCATIONS OF THE GREAT TOE SESAMOIDS 837 

Diagnosis is usually easy; crepitus and deformity are nearly always 
present. If there is much swelling and several toes are involved, the 
Roentgen picture may show cracks and separations of corners of the 
phalanx where fracture has not been suspected. 

Treatment. — Treatment of open fractm-es is that gi\'en in the general 
chapter. Usually the dressing applied holds the toe in good alignment, 
or it may be strapped to neighboring toes. This is not so true of the 
great toe, especially in oblique fracture of the proximal phalanx. If 
a bandage is run around the dressing, it tends to force the toe laterally 
so that it comes to assume a position of hallux valgus, and niay seriously 
interfere with walking or be very painful in weight-bearing. Con- 
sequently when the great toe is involved it seems best to pay special 
attention to maintaining it in good position, and a lateral splint of a 
narrow piece of wood on the median side of the foot will permit the 
toe to be held straight by adhesive or a narrow bandage. Recently 
I have had to operate on a toe healed in malposition of abduction, 
following oblique fracture of the proximal phalanx, because the point 
of the proximal fragment and the callus pointed out on the inner side 
of the toe and prohibited shoe wearing. 

FRACTURES AND DISLOCATIONS OF THE GREAT TOE 
SESAMOIDS. 

These sesamoids lie in pairs beneath the metatarsal phalangeal 
joint in the tendon of the flexor brevis hallucis muscle and are more 
common in males than females and in those of active muscular habits 
than in sedentary persons. The upper surfaces, which articulate with 
the grooves in the metatarsal heads, are flat and smooth; the plantar 
surface is rough. The bones are united to each other and the proximal 
phalanx by strong fibrous bands. They appear as bone about the 
eleventh year. Injuries to them are caused by direct violence of a 
weight falling on the joint, a squeezing of the joint between masses, 
or in falls when the impact is received in their area, or by. a sudden 
increase in weight-bearing force when one is carrying heavy objects. 
Most cases are overlooked on account of other more serious injuries, 
or because no roentgenogram is made. 

Sixteen cases were collected by ]\Iuller,^ including 1 of his own, 14 
of which were in males, 1 in a female and 1 not stated; 9 were in the 
right foot, 6 in the left foot; the external or fibular sesamoid was 
broken in 1 case, the internal in 9; and in 5 there was division of 
the sesamoid of both great toes, although but one foot was injured. 
Fracture is differentiated by the finding of the sharp irregular wedge 
and not a smooth contour. Speed^ reported 5 additional cases, 4 
being of the tibial sesamoid. 

Diagnosis depends almost entirely on the Roentgen picture, but a 
persistent point of pain on deep pressure over the locality of the 

> Ann. of Surg., Iv, 101. 2 Ibid.. Oftf)hcr, 1014. 



83S 



FRACTURES OF THE CALCANEUS 



sesamoids, following injury, leads to the diagnosis of probable frac- 
ture. The callus may cause pressure pain by its exuberance or by 





Fig. 634. — Transverse fracture 
of great toe sesamoid accompanied 
by fracture of the distal phalanx. 



Fig. 635. 



-Lateral view of a fractured 
great toe sesamoid. 



irritation of the tendon sheath (Figs. 634, 635, and 636). Pseudo- 
fracture in bipartite bones must be excluded.^ 

Simple treatment is given by the use of a 
circular pad with a centre opening placed 
around the bone and worn inside the boot 
like an ordinary bunion plaster. Or the 
injured bone and its companion may be 
removed. Miiller did this in one case by 
an incision parallel to the flexor longus 
hallucis tendon, but an easier approach is 
made by a lateral incision on the outer side 
of the great toe, as I have described. Both 
bones must be removed to avoid pressure 
symptoms, which develop if one is left alone 
and unsupported. Spontaneous healing un- 
doubtedly follows true fracture treated by 
rest and protection. 

I have seen one case of dislocation of these 
two sesamoids following an old posterior dislocation of the great toe. 
They caused some pain by pressure in their new environment, but 
this gradually wore off. 




Fig. 636. — Bipartite tibial 
sesamoid. 



1 References for sesamoid fracture: Schunke, Monatschr. f. Unfallheilk., 1901, p. 242; 
Marx, Miinchen. med. Wchnschr., 1904, li, 1688; Muskat, Deutsch. med. Wchnschr., 
1906, xxxii, 1319; Inglestein, Deutsch. Ztschr. f. Chir., 1908, xciii, 505; Mass, Inaug. 
Disser., Berlin, 1912; Geist, Am. Jour. Orthop. Surg., 1915, xii, 403; Boardman, Surg., 
Gynec. and Obst., xxi. No. 3, p. 394. 



CHAPTER XXVIII. 
ANKLE AND FOOT DISLOCATIONS. 

Anatomy and Landmarks. — In the chapter on Fractures of the Tibia 
and Fibula the rehitions and anatomy of the ankle moriise have been 
touched upon. Practically all motions in the ankle are dorsiflexion 
when the dorsum of the foot is drawn toward the front of the leg, 
and extension when the heel is drawn up and the toes are pulled toward 
the ground. Lateral movements are restricted because the ankle 
mortise embraces the talus very snugly, and the strong tibio- 
fibular ligaments hold the two leg bones together. The give in the 
ankle ligaments and the bending of the fibular shaft permit slight 
motions sideways. 

The shape of the mortise and the anterior and posterior lip of the 
tibial articular surface, aided by the deltoid, posterior talofibular, and 
calcaneofibular ligaments resist backward dislocations of the talus 
and ankle. In front the anterior talofibular ligament limits dorsi- 
flexion and aids in restraining the talus from anterior luxation. 

Subcutaneous projection of the malleoli makes them the prominent 
landmarks of the ankle, the outer lower than the inner. The front 
of the head of the talus can be palpated just in front of the external 
malleolus, differentiation being afforded by the fact that it moves 
when the foot is flexed and extended. The calcaneus is palpable on 
the outer and posterior surfaces, and the long axis of the tibia 
prolonged passes through the centre of the talus, as previously 
described. The na\'icular, cuboid, and metatarsal bones can also 
be identified in a foot which has not been traumatized, but the quick 
reaction of swelling precludes exact localization of the bones. Foot 
length is measured from the end of the great toe to the posterior border 
of the heel with the tape drawn taut from the hollow of the foot. 
This measurement is of considerable diagnostic help in determination 
of shortening of the foot in some dislocations, because it is subject to 
little variation on account of swelling. 

(1) True ankle or tibiotarsal dislocations are rare. Wendel' made 
a collection of 108 cases uncomplicated by fracture of either leg or 
tarsal bones. It must be admitted that anteroposterior ankle luxa- 
tion does occur, but in most instances the malleoli or the anterior and 
posterior surfaces of the tibia are fractured (see Lipping Fracture at the 
Ankle for statistics, etc.). Lateral luxation at the ankle necessitates 
fracture or complete separation of the tibia from the fibula, and the 
talus is not luxated in an exact horizontal displacement but is rotated 

Beitr. z. kliri. C'hir., xxi, ]2'.i. 



840 



ANKLE AND FOOT DISLOCATIONS 



to one side or other on its long axis (see Pott's Fracture). The forms 
of true dislocations at the ankle which have been reported may be 
classified as forward, backward, inward and outward. Dislocation 
upward is an accompaniment of a severe type of ankle fracture char- 
acterized by malleolar fracture, diastasis of the leg bones, and the 
forcing upward of the talus between. Wendel's collection contained 
four cases of true upward dislocation without fracture. For this 
displacement to be effected all ligaments between the talus and leg 
bones and the tibiofibular ligaments must be ruptured without bone 
damage. 





Fig. 637. — False forward dislocation at the 
ankle. Note that the talus retains its relation 
to the inferior surface of the tibia, the displace- 
ment occurring above at the site of impacted 
fracture. The projecting lower tibial fragment in 
front might be mistaken for the talus. 



Fig. 638. — Epiphyseal separation 
of the lower end of the tibia with 
some displacement of the foot back- 
ward. This is a false dislocation. 



Forward Dislocations. — Forward dislocations are seldom seen 
without fracture of the anterior tibial lip. Stimson^ found 10 cases 
in the literature (Fig. 637). Hyperextension of the foot from force 
applied to the leg or opposite forces acting, one on the back of the 
heel the other on the front of the ankle, as in squeezes of the foot, 
may produce this type of luxation. The heel rides forward and is 
shortened, while the forefoot seems lengthened and lies extended. 
If the case is seen before swelling has occurred, the talus may be 



1 Fractures and Dislocations. 7th ed.. p. 892. 



BACKWARD DISLOCATIONS 



841 



felt anteriorly bulging in front of the lower tibial margin. Asso- 
ciated anterior lipping fracture permits more motion than a pure 
luxation forward. Reduction is easily performed by the surgeon 
pressing the foot backward, holding the leg above the ankle. A 
plaster shoe applied with the foot held at a right angle is worn for 
four weeks. 

Backward Dislocations. — The cause of backward luxation is exces- 
sive dorsiflexion of the foot, aided by pressure in the long axis of the 




Fig. 639. — Incomplete dislofation backward at the ankle accompanied by fracture oi 
both malleoli and the posterior tibial lip. 



leg bones. Lateral and anterior ligaments rupture, and the talus is 
forced down under the tibial edge and out posteriorly. ]\Iost of the 
so-called posterior luxations are complications of ankle fracture, 
either Pott's or the posterior lipping fractures previously described 
(Figs. 038 and 639j. If the external malleolus and its ligaments are 
fractured, we expect the foot to lie in some eversion as well as pos- 
terior luxation. Most of these luxations are incomplete or subhixations 
and but recently have been recognized as compHcations of the t'rac- 



842 



ANKLE AND FOOT DISLOCATIONS 



ture, the true lesion. Heiilly and Boeckel^ reported an incomplete 
backward dislocation with a fracture of the fibula three inches above 
the malleolus. The lower fibular fragment accompanied the tarsal 
bones (see Ankle Fractures) (Figs. 640, 641, and 642). Pakowski and 
Cottillon^ reported a recent case of tibiotarsal backward dislocation 
in a thirty-four-year-old man who fell off a ladder. The ankle was 
swollen, the internal malleolus seemed about to pierce the skin, and 
there was bimalleolar thickening. Backward displacement of the 
heel for an inch was the striking point in appearance, and the forefoot 
was shortened. The foot was slightly extended but did not deviate 
from its normal axial line: measurement from the internal malleolus 
to the point of the heel was IJ cm. longer on the injured foot. Frac- 




FiG. 640.- 



-Complete backward dislocation with fracture of the posterior lip of the tibia 
and the external malleolus. 



ture of the fibula at the middle third was present, but the malleoli 
were normal. Spontaneous movements of the foot in true luxation 
are not possible, and passive movements are both limited and painful, 
particularly dorsiflexion. The talus and navicular bone appear 
to be normal in their attachments. Open wound may be caused by 
the violence, and the lower end of the tibia can be palpated in front 
of the ankle-joint. The calcaneus tendon is pulled backward into 
unusual prominence, and hollows form in front of it toward the mal- 
leoli. 

Reduction is made under anesthesia by the attendant pressing 



1 Rev. d'Orthop., Paris, 1911, 3 S, ii, 249. 

2 Bull, et mem. d. 1. Soc. Anat. de Paris, 1912, 6 S, xiv, 200. 



BACKWARD DISLOCATIONS 



843 




Fig. 641. — Complete backward dislocation with fracture of the external malleolus uiul 

epiphyseal separation. 




Fio. 642. — Complete backward and upward dislocation with li|)pinK fracture and 
fracture of the oxtcrnal iniillcoliis. 



844 



ANKLE AND FOOT DISLOCATIONS 



the heel forward and flexing the forefoot, after which a plaster shoe 
or posterior moulded plaster splint is used to prevent the foot from 
slipping back again. 

Inward and Outward Dislocations. — Inward and outward disloca- 
tions at the tibiotarsal joint are practically always accompanied by frac- 
ture, and the discussion of ankle fractures is intended to cover these 
(Fig. 643). Many of them are open dislocation, fractures involv- 
ing one or both malleoli or the talus (Fig. 644). They are caused by 
extreme violence exerted in the m<echanism of inversion and eversion 




Fig. 643. — Complete inward dislocation of the 
foot at the tibiotarsal joint without discoverable 
fracture. Note the position of the foot which 
is outlined at right angles to the leg. 




Fig. 644. — Outward ankle 
dislocation with malleolar frac- 
ture. 



of the foot. Most of the older reports in the literature were not con- 
firmed by roentgenogram, and the scarcity of recent reports confirms 
the ideas expressed on the intimate necessary relationship between 
fracture and dislocation on subsequent displacement. Almost any 
degree of distortion of the foot may follow torsional strains at the 
ankle, especially if an open wound results. The sole of the foot may 
be twisted to an angle of 90 degrees from the normal position. Reduc- 
tion is not difficult and the cases are treated from the standpoint 
of open or closed fracture rather than that of dislocation (Fig. 645). 



TALUS DISLOCATIONS 



845 



Unreduced cases of all types of ankle dislocation may result in 
sloughing of the soft parts covering the luxated bones. The pathological 
process is one of pressure necrosis from the bones, superinduced by 
the trauma on the parts in the causative violence. Formerly primary 
amputation was frequently advised and performed, but conservative 
antiseptic treatment is now persisted in because secondary resections 
of isolated bones or the whole joint lead to a useful foot. After infec- 
tion is established the joint must be given drainage in both front and 
rear, and the foot should be prevented from drooping. A resulting 
ankylosis with the foot at right angles to the leg looks toward a fair 
functional use. 




FiG.^645. — Backward and upward foot dislocation without fracture. The tibia 
and fibula are separated. Drawn from the case of Pakowski and Cotillon. 

TALUS DISLOCATIONS. 

By this term we understand total dislocations of the talus alone, 
not of the whole foot with its bones, as described in the preceding 
paragraphs covering dislocation of the ankle. To establish total 
luxation of the talus the connections with the tibia, fibula, navicular 
and calcaneus must be severed; that is, the talocrural and the talo- 
tarsal joints are involved. In the discussion of fractures of the talus, 
its function as a transformer of direct motion between the bones of 
the leg and the foot was discussed. The mechanism of displacement 
of the talus is not completely understood, although its luxations are 
more frequent than true ankle dislocations. It has no muscle attach- 
ments, and its displacement probably results from being squeezed 
out like a pit from a cherry. So numerous are the possibilities of tahis 
injury and displacement that Cotton^ has described 11 different lesions. 
Xo better classification than that of Stimson can be offered, and it is 
generally adopted. 



' Am. Jour. Surg., xxviii, No. 1, p. 32. 



846 . ANKLE AND FOOT DISLOCATIONS 

Talus displacements are (1) forward; (2) outward and forward; 
(3) inward and forward; (4) backward, and (5) rotatory, the last 
class including those displacements in which the bone still remains 
within the confines of the ankle mortise. In 1855 Malgaigne collected 
()5 cases, and Kronlein, in 400 fresh traumatic dislocations, found none 
of the talus, A very careful review of the literature was made in 1914 
by Schmitt,^ with a discussion of the value of operative treatment. 
Double luxation of the talus was reported by Boyer in 1803, and a 
second case by Sick in 1892.^ Fracture complicates over one-fifth 
of the cases; Schmitt found 21.1 per cent, fractured in 95 cases of 
dislocation. In Sick's case the talus was comminuted into four pieces. 
Open dislocation is also frequent, 44.2 per cent, in Schmitt's list, and 
the consequences of infection, stiff joints, amputation, and death are 
frequently observed. The posterior tibial artery is occasionally rup- 
tured (twice in Schmitt's list) and the posterior tibial nerve has also 
been reported torn once. 

The causes of talus luxation are like those of other ankle injuries: 
forced abduction of the foot, falls from heights, and twisting violence 
when the foot is caught between heavy objects or wheels of vehicles, 
the talus suffering as the go-between of the leg and forefoot. Liga- 
mentous rupture occurs first, and compression or torsion transmitted 
from above or below forces the bone out of position. 

Forward dislocation is rare. The bone is pushed directly forward 
and may rupture the extensor tendons lying in front. In the few cases 
reported fracture of the malleoli or calcaneus has been present. Pal- 
pation discovers the talus in an anterior position turned to any degree, 
in one case the posterior surface looking directly forward. An open 
wound may be present, and the bone lies free on the front of the 
ankle. Fenwick^ reported an interesting case of dislocation of the 
calcaneus accompanied by a partial forward luxation of the talus. 
The patient was an eighteen-year-old boy whose foot was crushed 
between a steamer and a wharf. No pulsation could be felt in the 
foot, which was nothing but a bag of blood. A smooth rounded 
projection could be felt below the external malleolus, but the bony 
prop in the heel was absent. After amputation dissection demon- 
strated that the calcaneus was twisted completely over on its side 
and the talus was partly dislocated directly forward, the head being 
tilted up lying on the dorsum of the foot over the navicular. There 
were no fractures. 

Dislocations outward and forward are the usual luxations, 32 of 
the 95 cases collected by Schmitt. The forefoot is bent inward in 
marked adduction, and the sole is inverted (Fig. 646). A protrusion 
of the talus brings it into a position overlying the triangular bone on 
the outer aspect of the dorsum of the foot, and as many of the cases 
have open wounds the bone lies in the opening. It may be fractured 

1 Deutsch. Ztschr. f. Chir., Leipzig, 1914, cii, 321. 

2 Berlin, klin. Wchnschr., 1892, 24, p. 580. 

3 British Med. Jour., London, 1911, i, 252. 



TALUS DISLOCATIOXS 



847 



or displaced in any angle on its long axis. This luxation is probably 
caused by torsion in forced pronation of the foot, and the inner 
malleolus is frequently fractured. Active and passive movements are 
restricted, and the foot is rigid. 

Dislocations inward and forward are less common than the preced- 
ing type. The foot assumes an opposite deformity, being turned out 
in eversion and abduction, and the talus is displaced forward and 
inward, rotated at any angle on its long axis. This type is also fre- 
quently an open dislocation, and fractures of the tarsal bones and 
malleoli may accompany it. 




Fig. 646. — Outward and forward dislocation of the talus with fracture. 

inner side. 



Seen from the 



Dislocation inward is rare. The newer literature contains two cases : 
V. Bramann's case, referred to by Baumgarten,^ and Schlatter's.^ 

Dislocations backward have included only part of the bone in most 
cases. Stimson collected 17 instances, 8 of which had suffered frac- 
ture of the neck of the bone with the posterior fragment alone luxated. 
The bone may go directly backward or to one side and is generally 
rotated. The tendon groups of the foot are displaced to one side of 
the bone. By inspection and palpation the talus can be made 
out back of its usual position pressing against the calcaneus tendon 
or pointing to one side of it. If the whole bone is luxated, the tahis 



Dis.sert. Halle, 1896. 



2 Boifr. z. kliii. ri.ir., 1S(M, lid. 11, 



848 ANKLE AND FOOT DISLOCATIONS 

is lacking when the front of the joint is palpated and the foot is in dorsi- 
flexion with a depression on the dorsum back of the navicular bone. 
Reduction is difficult, and the results were not highly satisfactory 
after manipulative return in the few cases in which it was accomplished. 
Traction on the forefoot, extension with direct pressure on the talus 
while inversion of the foot is being made, has accomplished reduction. 

Rotatory dislocations do not include those displacements of the 
talus so common in ankle fractures. Two types of true rotatory luxa- 
tion exist. In the first type the bone rotates on its transverse axis 
but still remains within the ankle mortise, and in the second the talus 
lies in a normal relation to the ankle mortise but has been rotated on 
its anteroposterior axis. In the first type the bone may be rotated 
the complete 90 degrees and lie on its side in the mortise; Stimson 
mentions 7 cases of the second type found in the literature. 

Treatment of the Total Dislocations of the Talus. — The older reports 
in the literature showed that 3 cases in 5 were successfully reduced 
by manipulation. Probably some of these cases were not pure talus 
dislocations but were fractures of the calcaneus. In less than half 
the cases on record either primary or secondary removal of the bone 
was performed with some secondary amputations and deaths from 
sepsis. In a few instances the bone remained unreduced. 

For closed luxation effort should be made to reduce as soon as 
possible by manipulation. The Thomas foot wrench is an excellent 
instrument with which to effect manipulation of the foot in order 
to aid reduction, because it gives a powerful leverage on the forefoot. 
The patient is anesthetized, the leg is flexed that the calcaneus tendon 
may relax, and the wrench is so applied to turn the foot in the direc- 
tion indicated by the position of the talus, so as to widen the aperture 
between the bones, and thus enable the talus to be pressed directly 
back into position. Tenotomy of the calcaneus tendon may be of 
some assistance. Failure of manipulation indicates attempt at open 
reduction. Most talus luxations which are not primarily open soon 
become so, if unreduced, from pressure of the bone on the soft parts, 
and serious infections are induced. When there is no fracture, open 
reduction may be accomplished. Roquetta^ advised open arthrotomy 
at once rather than leaving of the bone out of position and exposing 
of the patient to a secondary sloughing of the soft parts. Fracture 
complication renders removal of the dislocated fragment (if only one 
is dislocated) imperative. Malgaigne stated that the inferior part of 
the bone had a richer nourishment than the posterior portion which 
receives hardly any vessels. The surgical rule at present is to remove 
the dislocated portion and leave the fragment which is in place. It 
may necrose, and if it does a second operation is indicated. Schmitt, 
quoted previously, is in favor of total extirpation after careful review 
of 95 cases. The foot is not much shortened, and function is fair. 
Middeldorff's second case^ had 1 cm. shortening of the foot and Lan- 

1 Arch. gen. de Med., 1883, S ii. 

2 Mlinchen. med. Wchnschr., 1886, S, 929, U. 952. 



SUBTALUS DISLOCATIOXS S49 

derer's^ case 2 cm. after extirpation. Von Bergmann- had a patient 
with extirpation who could run well seventeen years afterward. 

Open dislocations depend on the injury of the bone in addition to 
the luxation. I have seen one without fracture reduced with a fair 
functional residt. When fracture is present, removal of the whole 
bone is the treatment of choice. In any case when the patient cannot 
be controlled under good hospital conditions, total extirpation with 
drainage is best. The foot is held at a right angle during healing. 
No stitches should be put in the skin wound, but a large aseptic 
dressing strengthened by a moulded plaster splint should hold the foot, 
and passive motion is begun in the second week if tenotomy has not 
been performed. Weight-bearing is prohibited for six to eight weeks 
and then is permitted in a closely fitting ankle support. The results 
after reduction of closed luxation are satisfactory, and the foot may 
return to a normal condition. A similar statement may be made 
of uninfected open reductions, but the infected cases lead to prolonged 
disability and frequently to amputation. From a limited experience 
in recent dislocations but a broader one in secondary operations on 
the infected bone, I am inclined to favor immediate extirpation with 
wide drainage. Expectant treatment of the unreduced bone is to be 
condemned; it may lead to serious sepsis. Functional results after 
extirpation are not startling, but the patient is able to be up and around 
and does not usually need the repeated operations for infected bone 
and the long course of repair with its necessary inactivity. 

A unique case of supposed luxation downward of the calcaneus was 
reported by Horand.^ The patient was a fift} -six-year-old man 
who had sustained a fracture of the external malleolus, and the cal- 
caneus was found standing at a right angle. Destot and Gallois"^ inves- 
tigated the case and found that the position was really an acquired 
pes calcaneus caused by a leg paralysis which had lasted forty-eight 
years instead of a recent injury of three months reported by the 
original writer. The only case of calcaneus luxation I can find is that 
of Fenwick, mentioned previously. 

SUBTALUS DISLOCATIONS. 

These luxations embrace those occurring below the talus, a bone 
which remains in more or less normal relationship with the ankle 
mortise. Luxation of the foot, including the calcaneus, necessitates 
a freeing of the tarsal navicular and cuboid, plus freeing of the cal- 
caneus from the talus and a maintenance of their relationship to each 
other after the lone tarsal bone is left in the ankle-joint. Possible 
displacements are divided into four varieties. Inward and outward 
are the most common positions, inward being the ordinary finding. 

1 Zentralbl. f. Chir., 1881, S. 609. 

2 Arch. f. klin. Chir., 1893, Bd. xliii, H. 3, S. i. 

3 Lyon Med., 1912, cxviii, 1289. 
* Lyon Chir., 1912, viii, 311. 

54 



850 



ANKLE AND FOOT DISLOCATIONS 



A few rare instances of luxation forward or backward have been 
recorded. 

Inward subtalus dislocations are caused by forcible inversion and 
adduction of the foot received by violent twists or falls when the 
body weight forces the leg down on the adducted foot (Fig. 647). 
The cuboid and calcaneus are displaced inward and generally a little 
backward, so that the head of the talus overrides the cuboid. Frac- 
ture does not often accompany this luxation. The dorsum of the 
foot is shortened, and the malleoli are found in normal relation upon 
palpation, but the inner malleolus is more prominent. All the toes 




Fig. 647. 



-Subtalus dislocation inward. There has also been a fracture, but it is 
impossible to isolate it more clearly in the roentgenogram. 



are drawn into adduction. A projection caused by the head of the 
talus anteriorly is the important point in diagnosis. If swelling has 
not obliterated the findings, the head can be felt and seen sticking 
outward away from its position next to the navicular. The calcaneus 
seems twisted and lies at the same angle as the rest of the foot, and 
the sustentaculum tali may be palpated beneath the skin on the inner 
side of the bone. Differentiation must be made from bimalleolar 
fracture at the ankle and fracture of the talus with lateral displacement. 
Intact malleoli, palpation of the head of the talus, lack of crepitus, 
and the rigid inversion of the foot with shortening of the dorsum estab- 
lish a diagnosis. Roentgenogram should be made for confirmation 



SCBTALUS DISLOCATIOXS 851 

and for establishing presence or absence of accompanying fracture. 
Mediotarsal luxation is also confused with this dislocation. 

Outward dislocation is caused by force acting on the inner side 
of the foot displacing the bones outward instead of inward, as described 
in the preceding type. The talus remains in the ankle mortise, the 
cuboid and calcaneus are pushed outward, and the talus appears as 
a prominence on the inner side of the foot with a depression in front 
of it. Abduction of the toes is present, and the internal malleolus 
is prominent and nearer the ground, the external malleolus being lost 
in the tissues displaced with the calcaneus. Before swelhng has ensued 
the navicular may be felt on the outside of the anteroposterior foot 
axis with a depression behind it. Varying degrees of obliquity of the 
foot are possible, and fractures of tarsal bones or diastases between 
them may also be complications. 

Dislocations backward and forward are extremely rare. In the 
backward type the navicular is depressed to lie beneath the talus, the 
calcaneus is drawn back and up to lengthen the heel, and the foot is 
in extreme extension. The forefoot may be angularly displaced. 
The malleoli are prominent and in front of the joint the talus 
sticks out as if it would burst through the skin. Rigidity of the foot 
and a shortening of the distance from the inner malleous to the tip 
of the hallux are additional symptoms. Forward dislocation gives 
the re^'erse deformity. Lengthening of the dorsum of the foot and 
shortening of the heel are present. The malleoli seem to be in contact 
with the calcaneus tendon, and beneath the tense extensor tendons 
on the dorsum of the foot no bony prominences can be palpated. 
The posterior articular lip of the tibia may be plainly felt beneath 
the calcaneus tendon. Palpation and roentgenogram exclude fracture. 

Diag:nosis. — General diagnosis of subtalus luxations depends on 
finding the talus in normal relation with the leg bones and not with 
the tarsal bones. The calcaneus is also in irregular position, but 
corresponds to the location of the rest of the foot. Extension and 
flexion at the tibiotarsal joint are not interfered with, but the rotatory 
movement in the joint below the talus is either inhibited or exaggerated. 

Treatment. — Reduction is attempted under anesthesia after fixation 
of the ankle, the knee also being flexed by an assistant. The surgeon 
exerts manual traction, pulling with one hand on the heel and the 
other on the forefoot, and swinging the foot around to meet the con- 
ditions of displacement. For inward luxation the foot is swung out- 
ward, for outward luxation, inward. Direct pressure on the anterior 
surface of the ankle downward may assist the reduction, which is 
generally easy and accompanied by a satisfactory jar as the bones 
-lip back. Manipulation failure will be an indication for open reduc- 
tion, which permits incision of restraining ligaments, the untangling 
of tendons, and the use of metal levers to pry the bones into position. 
Open luxations must be reduced as soon as possible and then cared 
for like other open wounds. Infection, gangrene, and uselessness of 
the foot indicate amputation. 



852 ANKLE AND FOOT DISLOCATIONS 

Prognosis. — The prognosis after reduction is good. Cotton^ records 
a case of recurrent talus luxation. The open cases are serious prob- 
lems, and primary amputation may be indicated if reduction cannot 
be made. With closed cases use of the foot is begun three weeks 
after reduction, and the ultimate function where it is stated in the 
records has been excellent. Irreducible cases which do not lead to 
infection or gangrene finally regain some function, but the foot is 
deformed and use is greatly limited. 

MEDIOTARSAL DISLOCATIONS. 

Luxation at the mediotarsal joint occurs by displacement of the 
cuboid and navicular bones away from their normal relations to the 
talus and calcaneus. Malgaigne made the first-named description 
of the luxation at this joint in 1855.^ 

The transverse tarsal or mediotarsal joint is found between the 
talus and calcaneus behind and the cuboid and navicular in front and 
is supported by the strong plantar ligaments aided by the insertion 
of the peroneus longus tendon. The calcaneocuboid joint is rigid, 
while the talonavicular joint, which lies higher, is more movable. The 
latter joint is for the head of the talus, which is sustained by the 
sustentaculum tali behind, the navicular bone in front, and below 
by the extremely strong inferior calcaneonavicular ligament, which 
is further braced by the insertion of the tibialis posticus tendon. 
Motion in the mediotarsal joint as a whole is a combination of that 
of the two joints described and consists of slight extension toward 
the plantar surface and some rotation about the longitudinal foot 
axis. 

Dislocations in the mediotarsal joint are divided into partial, or 
total, according to whether one or both of the joints mentioned is 
involved; complete and incomplete; and plantar or dorsal, according 
to the direction the peripheral bones take. Luxation at the lower 
part of the foot between the talus and cuboid cannot occur separately. 
The initial separation takes place between the talus and navicular, 
and separation of the second part of the joint follows. HonzeP searched 
the literature for all cases of mediotarsal luxations and thought he 
could select a total of 34.'* Mueller^ applied the crucial test of the 
roentgenogram to mediotarsal luxations and, including his own, listed 
12 cases. Skillern^ has added 1 case. Reports have also been made 
by Goebel,^ whose case was practically a pure dislocation of the 
navicular and internal cuneiform alone, and a subluxation in a nine- 
year-old girl, reported by Corson.^ I have studied the print of the 

1 Dislocations and Joint Fractures, p. 603. 

2 Traite des Fract. et des Luxations, ii, 1071. ^ These de Paris, 1911. 

4 Petit, Oeuvres Comp. Biblio. Chir., 1837, i, 98; Broca, Mem. d. 1. Soc. de Chir., 
1853, T. iii, 566; Cooper, Treatise on Fractures and Dislocations, 1823, p. 376. 

5 Fortschr. a. d. Geb. der Roentgenstrahlen, 1911-12, xviii, 187. 

6 Tr. Philadelphia Acad. Surg., xvi, 58. ^ Arch. f. Orthop., 1912, xi, 9. 
8 Ann. of Surg., 1912, Ivi, 883. 



DISLOCATIOXS OF ISOLATED TARSAL BOXES S53 

roentgenogram in this case and cannot see that it shows any snb- 
hixation. 

The causes are direct and indirect violence from hyperextension 
of the forefoot. It may be that repeated sprains and hyperextension 
injuries of the foot predispose to this hLxation by relaxing the ligaments 
and inducing flat-foot. After dislocation the foot is rigid, swollen, 
and has complete loss of motion below the ankle. Shortening between 
the inner malleolus and the end of the great toe is constantly present. 
When the luxation is dorsal, the navicular is seen and felt displaced 
upward and onto the dorsiun of the ankle in the partial type, and the 
cuboid accompanies it if the luxation is total. On the plantar surface 
the anterior edge of the calcaneus is correspondingly prominent. 
Plantar dislocation is more frequent. The cuboid and navicular are 
displaced downward into the sole of the foot, obliterating the arch 
and causing a bony projection there. On the dorsum of the foot the 
head of the talus and the anterior surface of the calcaneus form a 
bony protuberance, and over this ridge the extensor tendons can be 
seen and felt drawn taut. 

Treatment. — Treatment is immediate under anesthesia by dorsi- 
flexion or extension, according to the displacement, aided by direct 
pressure on the talus. Associated lesions of fracture, especially of the 
calcaneus, must receive attention. Early reduction avoids adherent 
tendons, loss of foot function, and a filling in of the joint surfaces 
left bare by the luxation which follows after non-reduction. The 
prognosis is good after prompt reduction. The strong ligaments of 
the foot are not torn, and the arch is not weakened. Irreducible cases 
or old cases can be improved functionally by tarsectomy, the operator 
removing the navicular and restoring the forefoot to a weight-bearing 
axis after reestablishing the arch. The foot is weakened and will 
need an arch support after weight-bearing is begun. Cotton^ records 
an open reduction of an unrecognized dislocation of a year's standing 
in a forty-six-year-old woman. Open reduction was performed, not 
for pain, but for clumsiness and uncertainty in use of the foot, induced 
by its marked inversion. 

DISLOCATIONS OF ISOLATED TARSAL BONES. 

Dislocations of isolated tarsal bones are not the rarity they have 
been considered. Examination by the Roentgen rays of traumatic 
injuries is bringing more reports of these luxations into the litera- 
ture, and a classification of them will slowly be established. 

Calcaneus dislocation w^as mentioned under the discussion of sub- 
talus luxations. Canton^ reported a case which he discovered in a 
cadaver. The calcaneus was displaced outward with the anterior end 
of the external malleolus lying between the navicular and cuboid. 

Navicular dislocations are more frequent. In 1910 BoeckeP pub- 

^ Dislocations and Joint Fractures, p. 607. ' Lancet, 1847, i, 505. 

3 Rev. de Chir., Paris, 1910, xxx, 102 and 280. 



854 



ANKLE AND FOOT DISLOCATIONS 



lished an extensive article on these dislocations, reporting Gross's and 
^Yeiss's cases from the clinic at Nancy. The navicular bone articulates 
with six neighboring bones, the calcaneus, talus, cuboid, and three 
cuneiforms, with the strongest ligamentous support on the plantar 
surface. Both the plantar and dorsal muscles and tendons help hold 
it in place. Luxations of the navicular are divided into navicular 
cuneiform separations, of which there are 16 cases recorded; talo- 
navicular separations, 17 cases; and total separations, seen when 
the navicular loses all connections with the surrounding bones. Of 
the last type there are 10 cases, and I am able to add another (see 
Figs. 648 and 649) . The navicular offers support to the blows received 




Fig. 648. — Total dorsal dislocation of the navicular. Fracture of the tuberosity. 

Lateral view. 

from the talus in falls, but on account of the slight angle of declination 
of the talus, which does not point directly forward, there is a struggle 
between the two bones (Fig. 650). The talus wishes to pass down- 
ward but is prevented by the navicular. It cannot go inward, because 
it is blocked by the tuberosity of the navicular, and there is conse- 
quently a luxation of the talus downward and inward, or of the navi- 
cular upward, frequently accompanied by fracture of the bony points. 
Destot^ calls this a traumatic flat-foot and assumes that the primary 
actor in the displacement is the talus, the navicular acting merely as 



Lyon Chir., 1898, iv, 495; and Rev. de Chir., 1898. 



DISLOCATIONS OF ISOLATED TARSAL BOXES 



S55 



a tampon, the queue of the fan formed by the three first metatarsals. 
He considers subtahis dislocations triple talus dislocations, inasmuch 




Fig. 649. — Anteropo-sterior view of total dislocation of the navicular. Note the broken- 

off tuberosity. 

as the latter bone leaves its connections with the tibia, calcaneum, 
and navicular (Figs. 651, 652, and 653). Destot states, without giving 




any details, that he has seen a great number of navicular dislocations 
in the last fifteen vears, and he considers that the term navicular 



m Fig. 650.— Total dorsal dislofation of the naM' iil;ir. riic ridge in the soft parts was 
■ caused by a strap the patient used to hold his slipper on. 



856 



ANKLE AND FOOT DISLOCATIONS 



dislocation should be applied only to total luxations of that bone, 
also that navicular cuneiform luxation should be considered cuneiform 
luxation. An instance of double dislocation was reported by Goebel.^ 
The patient was a thirty-two-year-old man. The feet were in an 
extended position, and there was much swelling, so that clinical diag- 
nosis of fracture of the calcaneus was made. Roentgen examination 
showed in the right foot a luxation of the navicular, with sprain frac- 
ture and periosteal elevation of the edge of the talus. The left foot 
showed complete uncomplicated upward dislocation of the navicular. 




Fig. 651. — Lateral view of ankle after removal of luxated navicular. 

fragment remains. 



The tuberosity 



An open operation was performed, and the bone was reduced and 
nailed to the talus. Infection followed, and the final result was a foot 
with one-third normal function. Linhart^ reported a double luxation 
downward, the navicular in one foot being displaced clear under the 
external malleolus. Boeckel's report of Gros's and Weiss's cases is 
one of the best in literature. Both patients were males aged twenty- 
six and nineteen years respectively, who had their feet injured by a 
wagon wheel passing over them while they were in a position of hyper- 



1 Deutsch. Ztschr. f. Chir., Leipzig, 1911, cxi, 238. 

2 Wien. Med. Presse, July 12, 1868, No. 28. 



DISLOCATIOXS OF ISOLATED TARSAL BONES 



857" 



extension and supination. There was great swelling, and a hard,, 
bony protuberance was felt on the dorsum of the foot. One had an 
open wound (Gros), and the roentgenogram showed fracture of the 




Fig. 652. — Anteroposterior view of foot after removal of navicular. 

external part of the cuboid and tuberosity of the fifth metatarsal, 
the navicular being completely luxated upward into the neck of the 
talus. Walking and all movements of the foot were very painful. 




Fig. 653. — Removed dislocated navicular. The surface articulating with the cunei- 
forms is turned forward. 



In the case of total upward dislocation which I had, the patient could 
walk quite well. The following is an enumeration of the cases of 
navicular luxation to date: 



858 ANKLE AND FOOT DISLOCATIONS 

1. Walker.^ Occurred in a stone mason; reduced by pressure of 
the thumbs; complete recovery in three months. 

2. Smith.'- An old dislocation which had never been reduced. 
The patient could walk fairly well with marked flat-foot. 

3. Roschke.^ 

4. Berger.^ • Reduction could not be accomplished; so the bone 
was removed by open operation, with an excellent result. 

5. Capillery and Ferron.^ A subluxation upward with no operative 
treatment and a fair result. 

G. Lemmen.*^ Total dislocation with fracture of the base of the 
fifth metatarsal. Reduction failed, so the bone was nailed. Suppura- 
tion followed. Patient walked after two months. 

7. Eichel.'^ Bone replaced by open operation. Some subluxation 
up and medially persisted, but the patient could work after six months, 

8. Gottstein.^ A doubtful case; no skiagram taken before reduc- 
tion. 

9. Gros. 

10. Weiss. Cases reported by Boeckel. 

11. My own case here illustrated. 

Double dislocations have been recorded by Piedagnet^ in 1831. 

12. Birkett, in 1865, cited by Paulet and Chauvel, reduction made 
immediately under chloroform.- Chaput,^'^ operative removal with a 
good result. 

13. Genzel,^^ double luxation upward. 

14. Linhart.i2 

15. Thiem's case^^ appears to be a downward dislocation of the 
whole forefoot at Chopart's joint. 

Bahr, in 1895, stated that the only true isolated navicular disloca- 
tions were those of Piedagnet, Walker, Smith, Linhart, Roschke and 
Birkett. Golebiewski stated that he saw 18 cases of fracture disloca- 
tion and subluxation of the navicular in his material, but none of the 
cases were verified by autopsy or roentgenogram. Diagnosis without 
the roentgenogram is difficult, and reduction by manipulation is 
also difficult. In my case the bone was excised. Quenu has done an 
excision on a luxation five weeks old with good result. The space 
between the cuneiforms and the head of the talus gradually closes in. 
Unreduced cases are exposed to all the secondary changes of arthritis 
and periarthritis, and it takes years to get the foot in a painless 
and useful condition. After extirpation an ankylosis of Chopart's 

1 Med. Exam., 1851, p. 203. ^ Dublin Hosp. Gaz., 1855, ii, 76. 

3 Th^se de Paris, 1856. 

4 Bull, et mem. d. 1. Soc. de Chir. de Paris, 1897, T. xxiii, 259. 

5 Rev. de Chir., 1906, T. xxxiv, 93. 

•5 XXXVI Congress of German Surgeons, April 5, 1907. 

7 Deutsch. Ztschr. f. Chir., 1907, 3 d, Ixxxviii, 324. 

8 Miinchen. med. Wchnschr., 1909, No. 28, p. 1430. 
^ Jour. Univ. et Hebdom., cited by Malgaigne. 

10 Bull, et mem. Soc. de Chir., 1890, p. 217. 

11 Ztschr. f. orthop. Chir., 1906, Bd. xv, 2, 4 Heft, p. 302. i^ Loc. cit. 
13 Monatschr. f. Unfallheilkunde, Leipzig, 1900, No. 10, p. 329. 



DISLOCATIOXS OF PHALAXGEAL BOXES 859 

joint may follow; Cuboid dislocations are practically unknown. Bell^ 
reported one case of displacement in connection with the fifth 
metatarsal. It was reduced. 

Cuneiform dislocations are more common, all three going out of 
place together, or the first one alone. Lemoine- collected 4 cases of 
the latter type, most of which were upward and inward. The first 
metatarsal may move with the cuneiform, flattening the arch of the 
foot. Other cases of dislocations of the second cuneiform, or all three 
together, appear in the literature, usually before the Roentgen period 
and without definite information of accompanying lesions. Reduc- 
tion is made by traction on the toes and direct pressure on the luxated 
bone. Dislocation of isolated bones is more difficult to reduce than 
that of groups of bones and excision most often is resorted to. 



DISLOCATIONS OF THE METATARSAL AND PHALANGEAL 

BONES. 

Dislocations of the metatarsal bones at Lisfranc's joint are fairl}^ 
common. In 1904 Bayer^ collected 68 cases, 34 of which were complete 
and 34 partial. Twent}- were dislocations of single bones with the 
following frequency : 

First metatarsal, 9 cases upward, 3 downward, 2 inward; second 
metatarsal, 1 case upward; fourth metatarsal, 3 cases upward; fifth 
metatarsal, 1 case outward, 1 downward. 

Isolated luxation of the third metatarsal has not been reported. 
A later collection in 1910 by Grunert^ contained 113 cases, 58 total, 
DO partial, 14 of the total number having been treated by operation. 
Only 4 cases were in women, and falls from a horse with the foot caught 
in the stirrup or under the horse was the most frequent cause. Her- 
mann' reported 2 cases, the first in a forty-two-year-old man who was 
climbing a ladder when a rung broke, dislocating his first four meta- 
tarsals upward but leaving the fifth in place. There were no fractures. 
The second one was in a nineteen-year-old boy; a 50 kg. weight fell 
on his whole foot, dislocating the second metatarsal upward without 
fracture. Reduction and casts gave good results in these cases within 
six weeks. 

^lost of the dislocations are caused by direct violence and are not 
often complicated by fracture, but there may be fracture of any of 
the individual metacarpal or carpal bones. The causes in Bayer's 
collection were springs or falls on the foot, 13; fall of heavy objects 
on the foot, 14; horse stepping on foot, 11, and so on. Among the 08 
cases 9 were not replaced. There was a good result in 30, 26 had poor 

1 New York Jour. Med., 1859, p. 329. 

2 Rev. de Chir., 1883, iii, 118. 

' Sarnmlurig, Klin. Vortnige, X. F., Xo. 372. 

* Deutsch. Zt.schr. f. Chir.. Bd. xfii. 

6 Beitr. z. klin. Chir., Bd. xciii, Xo. 1, p- 182. 



Total luxation 


Partial luxation. 


34 


34 


50 


46 


58 


55 


19 


15 


9 


7 



860 ANKLE AND FOOT DISLOCATIONS 

position, and of 7 operative repositions 5 resulted well.^ Hermann^ 
made the following compilation of the reported cases: 

Collection 

Bayer 68 

Lenormant 96 

Grunert .113 

Quenu and Kiiss 34 

Hermann (cases since 1911) . . . 16 

Dislocation of the first metatarsal is the most important, as it is 
along the line of this bone that the weight-bearing force is directed. 
Quenu considers this bone so important that he divides the foot into 
two planes, the inner one containing the tarsal bones and the first 
metatarsal, the outer one the other metatarsals. In treatment this- 
subdivision is of practical importance. 

Symptoms. — A typical case such as reported by Coullaud^ may be 
taken. A young man was riding a horse which slipped and fell, pinning 
the rider's leg beneath. The foot, which was in a position of slight 
extension in the stirrup, was violently adducted. The patient could 
not walk; his foot was in a valgus position and became quickly swollen. 
On the plantar surface the foot was swollen from the calcaneus to the 
head of the metatarsals, and the internal border was thickened and 
shortened as compared with that of the other foot. Movements in 
the tibiotarsal joints were normal, but the foot could not be rotated 
outward. The skin on the dorsum of the foot was tightly stretched^ 
and Chopart's and the tibiotarsal joints were painless. Roentgeno- 
gram showed a plantar luxation somewhat backward of the first 
metatarsal. Reduction was made by traction on the great toe and 
plantar pressure on the first metatarsal. The swelling subsided in 
fifteen days, and the result was excellent. The luxations occurring 
in equestrians when the horse falls are caused either by the weight 
of the man's body falling from the horse on his foot or the force of 
the horse's weight falling on the rider's foot which lies on the earth. 
Partial luxations involve the first metatarsal almost exclusively and 
are plantar. They are not difficult to reduce and give a good prognosis. 
Chaput^ reported an incomplete upward and outward dislocation 
of the first metatarsal. A heavy weight fell on a man's right foot, 
fracturing the third and fourth metatarsals in their anterior quarter. 
The mobility of the toes was greatly diminished and an angle formed 
at the tarsometatarsal line and the first metatarsal rose 1 cm. above 
and outside the external border of the first cuneiform. The second 
and third cuneiforms gave some evidence of fracture in the roentgeno- 
gram. The mechanism seemed to have been pressure on the anterior 
extremity of the metatarsals downward, tending to raise the other 

1 Lenormant, Arch. Gen. de Chir., Paris, 1908, No. 6; Quenu and Kiiss, Rev. de Chir., 
1909; Brockmann, Deutsch. Ztschr. f. Chir., Bd. cxix, 278; Worms and Hamant, Bull. 
et. mem. d. la. Soc. Anat. de Paris, 6th series, T. xiv, 99. 

2 Loc. cit. 3^j.c}i_ (je med. et pharm. mil., Paris, 1910, Ivi, 406. 
* Bull, et mem. d. 1. Soc. de Chir. de Paris, 1912, n. s., xxxviii, 302. 



DISLOCATIOXS OF PHALAXGEAL BONES SGI 

end of the bones. At the same time the cuneiforms were compressed 
from above downward. The two forces acting in an obhque direction 
caused the dislocation and carried the metatarsals outward. 

Total luxations of the metatarsals are grave injuries, and almost 
all of them are dorsal. One type, with or without fracture, is the 
divergent dislocation, with a diastasis of the first intermetatarsal 
space, the first metatarsal beiiig displaced inward, the other metatar- 
sals outward or out and upward. Quenu terms this the spatular type. 
The total dislocations, especially the divergent type, should be reduced 
at once, by traction on the toes. If swelling has already occurred, a 
total luxation may be put at rest with ice-bags and a reduction made 
later under anesthesia. Divergent dislocation should be reduced at 
once, especially the first metatarsal displacement. If traction fails, 
open operation should be performed for reduction of this important 
bone; the others can be reduced later by manipulation, or if they 
remain unreduced the function is fair. In any isolated irreducible 
dislocation of the metatarsals, or in recurring dislocation, the bone 
may be resected or nailed into place, the operation followed by the 
application of a plaster dressing to be worn for four or five weeks. 
Young^ reported three metatarsal luxations, two complete outward 
dislocations in which the forefoot was abducted and everted and the 
internal cuneiforms stood out prominently on the inner side of the 
foot. The reductions were easy, and after the foot was placed in 
plaster in slight adduction and inversion for three weeks the anatomical 
and functional results were good. His third case was a divergent 
dislocation, the first metatarsal being displaced completely inward, 
projecting under the skin on the inner side of the foot, and the others, 
except the fifth, being dislocated outward with some comminution 
of the bones. Reduction was made under anesthesia. Other divergent 
dislocations have been reported by Petit,^ Walther,^ Tuffier and Len- 
ger.^ The roentgenogram is quite necessary for positive diagnosis, 
but one can be made clinically on discovery that the forefoot forms 
an obtuse angle with the back foot and an angular deformity at Lis- 
franc's joint on the internal margin. A globular thickened shape 
of the dorsum, the tense extensor tendons of the toes passing over 
this mass, and widening of the internal border of the foot with an 
imprint of the wet foot which shows that the weight is carried in walk- 
ing on the outer side, are presumptive evidence. On the dorsum the 
bases of the four metatarsals can be palpated, between the first and 
second metatarsal a hole can be felt into which a finger point can be 
thrust, and the tubercle of the fifth metatarsal is unduly prominent. 

Walther's case was not reduced, and he believed it was better to 
leave it alone than to operate on it because an enucleation of tlic cunei- 
form would not influence it favorably. The functional adaptation of 

1 Glasgow Med. Jour., 1912, Ixxvii, 287. 

2 Arch, de Med. et Pharm. mil., Paris, 1911, Ivii, 28. 

' Bull, et mem. d. 1. Soc. de Chir., Paris, 1912, n. s., xxxviii, 190. 
* Ann. de la Soc. Med. Chir. de Li^ge, liii. 



862 ANKLE AND FOOT DISLOCATIONS 

the foot gradually improves, and much improvement is accomplished 
by reeducation of the movements of walking so that locomotion may 
become fair. Claudot found that in 11 cases of unreduced metatarsal 
luxation 8 could walk in a satisfactory manner, but 3 could not until 
after the expiration of several years. Quenu and Kiiss after studying 
6 unreduced cases concluded that the static and walking function 
gradually improved ; the longer the patient could be followed the better 
the functional results seemed to be.^ 

DISLOCATIONS OF THE PHALANGES OF THE FOOT. 
METATARSOPHALANGEAL DISLOCATIONS. 

Dislocations of the great toe are the most common (Fig. 654). 
They are caused by falls, by stubbing of the toe on one going upstair s^ 
or by kicks at objects. Malgaigne states that of 22 cases of luxations 
of the toes, 19 were of the great toe. An open wound may be present, 
and the proximal phalanx may be displaced upward, backward, or 
to one side, the head of the metatarsal frequently opening out through 




Fig. 654. — Recent backward and upward dislocation of the great toe. 

the plantar tissues. Cases have been reported by Rigden,^ Robinson,^ 
DeaP and Skillern.^ The last-mentioned case was displaced dorsally 
on the metatarsal and as usual in this luxation the sesamoids were 
separated, one going to each side of the metatarsal head. They did 
not interfere with reduction (Figs. 655 and 656). 

Treatment. — Reduction is made by traction or by a mechanism 
similar to Farabeuf's for reduction of thumb dislocations. The surgeon 
raises the toe to a right angle and makes strong pressure against the base 
to push it forward, rocking it on its way. This was first described by 
Dr. Crosby, of New Hampshire, in 1826. Chisholm*^ has suggested a 
method for reducing these luxations by a cutting of the extensor 
tendon of the toe, and a hyperflexing and pulling of it into position 
on the metatarsal. This method disengages the flexor brevis pollicis, 

1 Claudot, Arch. gen. demed. et de Pharm mil., Mai, 1886; Chavasse, Red. de Chir., 
1884, p. 542; Soison et Mangenot, Arch, de Med. et de Pharm. mil., mai, 1892; d'Arme- 
quin, Arch, de Med. et de Pharm. mil., juillet, 1895; Nimier, Gaz. des Hop., 1889, No.. 
15, p. 133; Hornus, Gaz. des Hop., 1902, p. 412. 

2 Lancet, London, 1914, i, 213. 3 ibid., p. 148. 
^ Jour. Am. Med. Assn., 1914, Ixii, 1086. 

5 Ibid., December 6, 1913, p. 2063. 

6 Canadian Med. Assn. Jour., December, 1914, No. 12. 



DISLOCATIOXS OF THE PHALANGES OF THE FOOT 8G3 

the abductor and adductor pollicis, the long flexor, and the capsule 
and makes the phalanx slip over the metacarpal head, pushing these 
structures before it. The divided extensor tendon is then sutured 
and the opening in the skin closed. This method should be used only 





Fig. 655. — Old dislocation backward 
and inward of the great toe following 
trauma. Note that the sesamoids are 
dislocated inward around the head of the 
first metatarsal. 



Fig. 656. — Reduction by operation of 
the preceding dislocation. The head of 
the metatarsal was trimmed off and a flap 
of capsule and fat was swung in between 
the bones as a modified arthroplasty. 
Note the correction. Result excellent. 



after the failure of Crosby's method, which seeks to accomplish the 
same end without an open wound. 

A few cases of dislocation of the other phalanges of the toes and the 
terminal phalanx of the great toe have been reported. They may be 
reduced bv traction or transfixion and traction. 



INDEX. 



A 



Abductiox mechanism of dislocation, 
161 
treatment of fractm*e of neck of 
humerus, 369 
Acetabulum, fracture of, 580 

central dislocation of head of 

femur, 582 

diagnosis of, 

583 
treatment of, 
583 
classification of, 580 
radiating, 581 
of rim, 580 
treatment of, 580 
Achondroplasia, 37 
Acromioclavicular joint, 310 
anatomy of, 311 
cartilage of, 313 
dislocations of, 311 
motions in, 311 
Adhesive plaster, use of, m rib fracture, 
338 
contra-indication for, 340 
Albee's bon€ inlay in treatment of frac- 
ture of leg, 766 
method of bone graft, 154 
results in, 155 
Allis's method of reduction in hip dislo- 
cation, 684 
reduction experiments in hip dislo- 
cation, 683 
Aluminum splints, 116 
Ambulatory splints, 118 
types of, 119 
treatment of delayed union in frac- 
ture of leg, 764 
in fracture of clavicle, 297 
American Surgical Association's report 
on classification of 
surgeons, 136 
on treatment of frac- 
ture, 121 
Amputations, indications for, 124 
statistics of, 125 
treatment of shock in, 125 
Andrews's imbrication method of patellar 

suture, 718 
Anesthesia in skull fracture, 208, 209 
Angle's method of wiring teeth, 231 
Angwine's method of wiring teeth, 230 
55 



Ankle-joint, anatomy of, 839 
dislocations of, 839 
backward, 841 

treatment of, 842 
classification of, 840 
forward, 840 
inward, 844 
outward, 844 
fractures of, 771 
eversion, 772 
inversion, 785 
medicolegal aspect of, 782 
mortise of, 773, 781 
Pott's, 778 

prognosis of, mathematical 
calculation of, 780 
sprains of, 774 
Ankylosis in jaw dislocation, 241 

Rochet's operation for, 241 
Aphasia in skull fracture, 196 
Aran's theorj^ of skull fracture, 186 
Arthritis, secondary, in wrist fractures, 

528 _ 

Arthroplasty in old elbow dislocations, 
499 
in unreduced dislocation, 182 
Arthrotomy in treatment of dislocation, 
180 
in unreduced dislocations, 182 
Articular fractures, 55 
Asphyxia in jaw dislocation, 241 

traumatic, in rib fracture, 338 
Astragalectomy in ankle fractures, 794 
Astragalus. See Talus. 
Atlas, fracture of, 262, 267 

subluxation of, 262, 264 
Autotransfusion, 124 
Avulsion of limb in dislocation, 179 
Axillary artery, injury to, in dislocation, 
178 
rupture of, in shoulder disloca- 
tions, 419 
pads, 297, 361 
Axis, subluxation of, 266 



B 



Ball-and-socket joint, leverage action 

of, 161 
mechanism of dislocation 

of, 161 
Bandages, Barton's, 229 



866 



INDEX 



Bandages, Bellamy's dressing for dislo- 
cation of clavicle, 316 
Collins's, 301 

crossed bandage of face, 229 
Desault's, 298 
Gibson's, 229 
Nichols and Smith's dressing for 

dislocation of clavicle, 316 
Peckham's, 298 
Sayre's, 299 
Velpeau's, 298 
Bardenheuer's extension in reduction 

of fracture, 110 
Bartlett's clamp, 146 
Barton's bandage, 229 

fracture, 485 
Bed-sores, 147 
Bellamy^s dressing, for dislocation of 

clavicle, 316 
Biceps tendon in shoulder dislocations, 

417 
Bickham's osteoplastic exposure of spine, 

285 
Bier's hyperemia in non-union of callus, 
83 
method of treatment in non-union 
of fracture of tibia, 765 
Bigelow's experiments in hip dislocation, 
683 
method of reduction in hip disloca- 
tion, 684 
Bilateral dislocations, 159 
Bladder rupture in pelvic fracture, 575 

treatment of, 578 
Bleb formation, 93 
Blindness in skull fracture, 196 
Blood-pressure in bursting skull fracture, 
203 
in skull fractures, 198 
Blood supply of small bone fragments, 27 
Bloodvessels, injury of, in dislocation, 
166 
diagnosis of, 178 
of shoulder, 419 
symptoms of, 178 
treatment of, 178 
in reduction of dislocations, 177 
Bone atrophy, 18, 38 

in carpal bones, 527 
blood supply of, 18 
button in skull operation, 212 
calcium balance in, 18 
carcinoma of, 39 
composition of, 17 
cysts, fracture and, 38 
diaphyses of, 19 
in disuse, 38 
dowels, 155 
drills, 145 
epiphyses of, 19 
formation of, 17 
fragments, irritation of, 27 

presence of, near joints, 27 
in regeneration of bone, 24 
removal of, 27 
graft, Albee's method, 154 



Bone graft, from fractured site, 155 

technic of obtaining, 
155 
inlay, 27 
intramedullary, 27 
wedge-shape, 155 
growth of, 18 
arrest of, 88 
exaggeration of, 88 
Wolff's law, 18 
hash, 206 

infection, course of, 31 
instruments, 156 
lamellar arrangement of, 19 
lymphatics of, 18 
malignant disease of, 39 
medullary plug of, 24 
metaboUsm of, 17 
nerve supply of, 18 
pathology of, 171 
periosteum of, 20 
physics of, 17, 18 
regeneration of, 19, 21 

after removal of bone splint, 

151 
of blood-clot, 23 
compact and cancellous, 23 
experiments on, 21 
necrosis in, 31 
osteoblasts, 21 
repair, 29 

in open fracture, 29 
replacement of, 213 
Roentgen-ray pictures of, 18 

variations of, 18, 19 
sarcoma of, 39 

splints, fracture after removal of, 
151 
intramedullary, 27 
absorption of, 27 
fate of, 27 
Lexer's theory, 28 
Macewen's theory of, 28 
necrosis of, 28 
relation of periosteum to, 

27 _ 
substitution of, 28 
use of fibula for, 151 
structure in relation to cause of 

fracture, 35 
transplant, Albee's, in fracture of the 
leg, 766 
fate of bone in open fractures, 

128 
Gallies's, in fracture of leg, 765 
transplantation, 27 
fate of, 22 

in patellar fracture, 720 
in spinal fracture, 285 
Wolff's law of, 22 
in unreduced dislocations, 171 

application of Wolff's law 

to, 171 
calcium equilibrium, 171 
wax in treatment of non-union of 
callus, 83 



INDEX 



867 



Brachial plexus paralysis in clavicular 

fracture, 292 
Bradford frame, 27-i 

in pelvic fracture, 578 
in treatment of fractures of 
femur, 6-46 
Brain, concussion of, 198 
Breast cancer, relation to pathological 

fracture, 41 
British Siu-gical Association's report on 
classification of sur- 
geons, 136 
on treatment of frac- 
ture, 121 
Bryant's iliofemoral triangle, 612 
Buckling fracture, 49 
Buck's extension, 617, 644 

in reduction of fracture, 110 
Bulbar paralysis in bursting skull frac- 
tiu-es, 203 



Cal a ressort, 87 
Calcaneus, anatomj' of, 813 

dislocation of, 846, 849, 853 
fractures of, 813 
aAiilsion, 815 

S3^mptoms and diagnosis 

of, 815 
treatment of, 815 
classification of, 813 
compression, 818 

after-treatment of, 823 
prognosis of, 821 
statistics of, 819 
svmptoms and diagnosis, 
^ of, 820 
. treatment of, 822 
occurrence of, 813 
sustentaculum taU, 817 
trochlear process, 818 
Calcar femorale in neck of femur, 592 
Calcification of acromioclavicular liga- 
ment, 314 
Calcium equilibrium, 37, 78 
Callus, calcification of, 76 
causes of, 75 
weak, 75 
course of, 25 

delayed union, 26, 76, 77 
diagnosis of, 77 
fibrous union of, 77 
occurrence of, 77 
pseudarthrosis of, 77 
development of, in comminuted 
fractures, 134 
of tumor in, 87 
differential diagnosis of, from neu- 
ritis, 74 
effect of alignment on, 25 
of foreign bodies on, 26 
of immobilization on, 24 
of massage on, 25 
of motion on, 25 



Callus, excessive, 32, 73 
expermients on, 26 
extra-articular, 32 
formation, 22 

effect of infection on, 29 
in elbow dislocation, 494 
in epiphyseal separation, 32 
in joint fracture, 31 
in malleolar fractiu'cs, 31 
in open fractures, 29 
malunion of, 85 
causes of, 85 

influence of reduction on, 85 
near joints, 85 
treatment of, 86 
near joints, 25, 32, 74 
nerve inclusion and, 86 

pathology of, 86 
injury and, 86 
non-union of, 32, 76, 77, 78, 80 
circulatory disturbances in, 81 
causes of, 78 

differential diagnosis of, 81 
effect of anatomical reposition 
on, 132 
of blood supply on, 80 
of internal splints on, 131 
functional disturbances in, 80 
influence of periosteum on, 80 
nervous influences on, 80 
operative treatment of, 84 
pathologj^ of, 79 
roentgenogram in, 80 
symptoms of, 80 
treatment of, 81 

Bier's hyperemia in, 83 
bone emulsion in, 83 

wax in, 83 
local injections in, 83 
massage in, 83 . 
Thomas's damming method 

in, 83 
Wolff's law applied to, 83 
painful, 73 
parosteal, 74 
provisional, 24 
refracture of, 76 
relation of "osteomyelitis to, 75 

of sarcoma to, 87 
Roentgen shadow of, 18 
snapping, 87 
vicious, 85 
weak, 73 
Capitate bone in wrist injuries, 544 
! Capsular tears in dislocation, 163 
I in unreduced dislocations, 170 

I Capsule phcation in shoulder disloca- 
I tions, 436 

! reefing in treatment of dislocation 

of patella, 730 
j role of, in reduction of dislocation, 

I 176 

Capsulorrhaphy in treatment of shoulder 
I dislocation, 435, 436 
' Capsulotomy in fracture of neck of 
humerus, 365 



868 



INDEX 



Carpal bones, dislocation of, isolated, 
554 
classification of, 543 
Codman's experiments 

on, 543 
mechanism of, 543, 554 
fracture of, 517 
capitate, 528 
hamate, 529 
landmarks in, 517 
lunate, 526 
multangular, 529 
navicular, 517 

anatomy of, 518 
bipartite, 518 
clinical types of, 520 
course and prognosis 

of, 523 
diagnosis of, 523 
mechanism of, 519 
pathology of, 521 
symptoms of, 522 
treatment of, 524 

operative, 525 
tuberosity, fracture of, 
521 
pisiform, 529 
statistics of, 517 
triangular, 529 
dislocations, capitate bone, 557 
hamate bone, 558 
lunate bone, 545, 547, 557 
posterior, 547 
volar, 546 
multangular bone, 558 
navicular bone, 556 
pathology of, 545 
pisiform bone, 559 
prognosis of, 542, 551 
subluxations, 545 
treatment of, 552 
Carpometacarpal dislocations of five 
metacarpals, 561 
second metacarpal, 560 
of thumb, 559 

recurrent cases, 560 
Carrying angle of elbow-joint, 356 

in supracondylar fractures of 
humerus, 398 
Cartilage in acromioclavicular joint dis- 
location, 313 
formation of, 21 
intervertebral, 249 
regeneration of, 21 
of rib. See Costal cartilages. 
Catheterization in pelvic fracture, 579 
Cavernous sinus, gunshot injury of, 209 
Centres of ossification, 23, 24 
Cerebrospinal fluid, 193 

in bursting skull fracture, 198 
circulation of, 194 
findings in skull fracture, 193 
in lumbar puncture, 195 
Cervical fracture-dislocation, Calot's 
collar, 269 
Thomas's collar, 269 



Cervical fracture-dislocation, treatment 
of, 269 
vertebrae, fractures and dislocation 
of, 260 
Cheyne-Stoke's respiration, 198 
Chisels for bone, 145 
Clavicle^ dislocation of, 304, 313 

acromial end, 310, 314, 317 
anatomy of, 310 
calcification of acro- 
mioclavicular liga- 
ment, 314 
pathology of, 313 
symptoms and diag- 
nosis of, 314 
treatment of, 315 
operative, 317 
backward, 309 
double, 319 

ligamentoplasty in, 318 
presternal, 305 

pathology of, 306 
prognosis of, 308 
symptoms and diagnosis 

of, 307 
treatment of, 307 
statistics of, 304 
sternal end, 304 
subacromial, 318 
subcorocoid, 319 
subluxation, 308 
syndesmopexy in, 318 
total, 320 
upward, 308 
fracture of, in children, 301 

differentiated from dislocation, 

294 
and dislocation of, 286 
anatomy of, 286 
causes and occurrence of, 

286 
in children, 290 
pathology of, 287 

complications, 292 
the extremities, 291 
the shaft, 287 
symptoms, diagnosis and 

course, 293 
treatment of, 295, 297 
double, 293 

examination of, in infants, 294 
results in, 295 
sternal end of, 291 
treatment of, 302 

indication for, 302 
operative, 302 
results of, 303 
technic of, 302 
ununited, 303 
ununited, 293 
separation of epiphysis of, 292 
Closed dislocations, 158 
Cobb's splint, 217 
Coccyx, dislocation of, 585 

fracture of, 585 
Coccygodynia, 586 






INDEX 



869 



Codivilla's extension, 156 

in reduction of fracture, 110 
nail extension in treatment of frac- 
ture of femur. 1)53 
Coerr's lever for reduction, 140 
Colles's fracture, 471 
Barton's, 485 
causes of, 478 

epiphyseal separation of, 477 
open. 476 
pathology of, 472 
prognosis of, 481 
reversed, 485 
sprain, 480 

symptoms and diagnosis of, 480 
treatment of, 482 
operative, 484 
Collins's modification of Sayre's dressing, 

301 
Comminuted fracture, 54, 134 

development of callus in, 134 
fate of fragments in, 134 
fixation in, 134 
rate of union in, 134 
Compression fractiu-e of vertebra, 248 
Concussion of brain, 198 

of cord in lumbar fracture, 277 
Congenital absence of patella, 703, 704 

dislocations, 158 
Conoid ligament in clavicular disloca- 
tions, 310 
in fracture, 291 
Constrictors, use of, in open fracture, 

124 
Contrecoup theor}- of skull fracture, 187 
Convulsions in bursting skull fractures, 

203 
Cook Countv Hospital operated frac- 
tures, 138 ^ 
Coronoid process, fracture of, 227 

dental nerve involvement 

in, 228 
prognosis of, 228 
treatment of, 228 
Costal cartilages, dislocation at costo- 
chondral junction, 336 
on vertebra?, 336 
fracture and dislocation of, 335 
course and prognosis 

of, 337 
pathology of, 335 
svmptoms of, 337 
treatment of, 338 
separation of cartilages from 
each other, 336 
Coxa valga, traumatic, 598, 608 

vera, traumatic, 598 
Cranial nerv^e involvement in bursting 

skull fractures, 203 
Crepitus, 94 

absence of, 95 
differential diagnosis of, 94 
in dislocation, 174 
methods of demonstrating, 94 
Cricoid cartilage, fracture of, 350 
Crossed bandage of face, 229 



Crucial ligaments, anatomy of, 735 
Cubitus varus, 410 
Cuboid, fracture of, 830 
Cuneiform bone, dislocation of, 859 
Cuneiforms, fractiu'e of, 830 
Cushing's pneumatic clamp, 212 
Cystitis, after spinal fracture, 278 



Danielsox's position for dressing dis- 
located shoulder, 426 
Deafness in skull fractiire, 196 
Decompression, 208 

advantages of early, 211 

indication for, 210 

results of, 213 

sites of, 211 

subtemporal, 211 
Decubitus, 147 

following spinal fracture, 278 

in spinal fractures, 260 
Definitive callus, 24 
! Deformity in dislocation, 173 
I in fractures, 92 

i Delaved union, 26 

of callus, 76 
Delirium tremens, 33 
Dennis's rule in fat embolism, 66 
Dental nerve involvement in coronoid 
process fracture, 228 
in superior maxilla fracture, 221 
Dentate fracture, 53 
Desault's bandage, 298 
Diabetes in skull fracture, 196 
Diaphragm rupture in rib fracture, 338 
Diaphragmatic hernia, differentiated 

from sternal fracture, 348 
Diastasis, 158 
Dislocations, 158 

acromioclavicular joint, 310 

after-treatment of, 183 

of ankle-joint. See Ankle-joint, dis- 
locations of. 

bilateral, 159 

caused by muscular action, 161 

of cervical spine, total, 268 

classification of, 156 

closed, 158 

of coccyx, 585 

congenital, 158 

of costal cartilages, 331 

course of, 167 

definitions of, 158 

deformity in, 173 

displacements in, 164 

of distal phalangeal joint, 568 

of elbow, 488 

differential diagnosis of, 403 

etiology, 159 

of fibula. See Fibula, dislocations 
of. 

of foot. See Foot, dislocations of. 

function after, 167, 183 

habitual, 158, 162, 180 



870 



INDEX 



Dislocations, habitual, pathology of, 163 
treatment of, 180 

by injections, 181 
operative, 181 
of hand and wrist, classification of, 

543 
of hip, 670 

of ilium in pelvic fracture, 580 
immobilization after, 183 
of inferior maxilla, 236 
injury to axillary artery in, 178 
of knee. See Knee, dislocations of. 
of lunate bone with fracture of navic- 
ular, 549 
massage after, 183 
mechanism of, 159 
abduction, 161 

influence of ligaments on, 160 
principle of leverage in, 160 
in specific joints, 161 
of metatarsal bone. See Meta- 
tarsal bones, dislocation of. 
multiple, 158 
muscle spasm in, 174 
nerve injury in, 179 
nomenclature of, 159 
old, after-treatment of, 183 
ankylosis in, 183 
final results in, 183 
open, 158 

operative treatment of, 180 
of patella. See Patella, dislocations 

of. 
pathological complications of, 164 
gangrene, 165 
involving bloodvessels, 165 
bone, 164 
nerves, 166 
viscera, 166 
open dislocation, 166 
perilunar dorsal, of hand, 546 
of phalanges of foot. See Pha- 
langes, dislocation of. 
recurrent, 163, 168 
reduction of, 176, 177 

complications of, 177 
aneurysm, 179 
bone, 179 
death, 180 
delayed, 180 

injury to bloodvessels, 178 
to nerves, 178 
to skin, 179 
dangers of, 177 
wild efforts, 178 
repair of, after reduction, 167 
of ribs, 331 
of sacrum, 584 

of second phalangeal joint, 568 
of semilunar cartilages, 807 
of shoulder. See Shoulder, disloca- 
tions of. 
spontaneous, 158, 162 
statistics of, 159 
of sternum, 345 
symptoms of, signs of, 172-174 



Dislocations of talus. See Talus, dislo- 
cation of. 
of tarsal bones. See Tarsal bones, 

dislocation of. 
of temporomaxillary joint, 241 
treatment of, 175 
arthrotomy, 180 
by manipulation, 176 
by traction, 175 
typical, 174 
unreduced, 168 

arthroplasty in, 182 
arthrotomy in, 182 
functional results in, 182 
osteotomy in, 182 
pathology of, 169, 170 
treatment of, 181 
use of roentgenogram in, 173 
of vertebrae, 243 
voluntary, 162 
of wrist, classification of, 537 
Distortions, 158 
Distraction, 158 
Dorsal vertebral fracture-dislocations, 

270 
Double dislocation of clavicle, 320 

inclined planes, 116 

Dowels of bone, 155 

Drainage after operation, 147 

in jaw fracture, 233 

in skull fracture, 209 

operations, 212 
of spinal cord following decompres- 
sion, 256 
Dreyer's sign in fracture of patella, 708 
Drills for bone, 145 
Duga's test in dislocation of shoulder, 

358 
Dupuytren's splint in ankle fracture, 781 
Dysphagia in hyoid fracture, 344 

valsalviana, 344 
Dyspnea in sternal fractures, 348 



Ear, involvement of, in jaw fracture, 226 

Ecchymosis, 93 

Edema of arm in shoulder dislocations, 

419 
Ehrlich's and Clairmont's capsulor- 
rhaphy in treatment 
of shoulder disloca- 
tions, 436 
Elbow, dislocation of, after treatment, 496 
backward, both forearm bones, 
489 
pathology of, 490 
callus formation in, 494 
diagnosis of, 493 
divergent, 507 

treatment of, 508 
forward, 505 

pathology of, 506 
symptoms of, 506 
treatment of, 507 



1 



INDEX 



871 



Elbow, dislocation of, iiiward, 505 
landmarks in, 488, 493 
lateral, 502 
nerve injury in, 494 
old, 496 ' 

in connection with frac- 
ture, 498 
pathology of, 497 
treatment of, operative, 
499 
results of, 499 
technic, 500 
outward, 502 

incomplete, 504 
pathology of, 502, 503 
sjTinpioms and diagnosis of, 

503 
treatment of, 504 
prognosis of, 494 
statistics of, 488 
symptoms and signs of, 492 
treatment of, 495 
tj-pes of, 489 
joint, 353 

anatomy of, 352 
carrying angle of, 356 
fracture of, examination of, 

394 
landmarks of, 355 
ligaments of, 352 
motions in, 353 
surface markings of, 355 
Embolism resulting from fracture, 90 
Emphysema following rib fracture, 335, 
342 
in sternal fractures, 347 
Englemann's splint, 117, 647 
Ensiform process, dislocation of, 348 

fracture and dislocation of, 
348 
Epigastric hernia differentiated from 

sternal fracture, 348 
Epilepsy following skull fracture, 206 
Epiphyseal centres of humerus, 
352 
separation, 32, 55 

arrest of growth in, 32 
callus formation in, 32 
at head of radius, 450 
of lower end of tibia, 768 
of neck of femur, 596 

diagnosis of, 597 
of olecranon process, 448 
of upper end of tibia, 746 
humeral, 372 
Epiphysis, growth of, arrest of, 88 
Ether rausch in forearm fracture, 
482 
in reduction of fracture, 104 
External internal sphnts, 156 
Allen's plate, 157 
Codivilla's extension, 156 
Lambotte's clamp, 156 
staples, 156 

Steinmann's extension, 56 
Extra-articular callus, 32 



Facial bones, fracture of, 214 

flaps in epilepsy, 206 
False mobility, 93 

methods of demonstrating, 94 
Fascia transplant in dislocations of 
clavicle, 308 
used as a hemostat, 212 
Fascial transplantation in shoulder dis- 
location, 436 
Fat embolism, 33, 63 

Dennis's rule in, 66 
experiments on, 64 
in fracture, 90 
means of avoiding, 66 
pathology of, 64 
statistics covering, 65, 66 
Femoral vessels, rupture of, in hip dis- 
location, 687, 693 
Femur, anatomy of, 589 

Bryant's iliofemoral triangle, 612 
dislocation of head, central. See 
Acetabulum, fracture of. 
at liip, 670 
fractures of, 589 
condyles, 665 
epicondyles, 665 

diagnosis of, 667 
pathology of, 666 
treatment of, 669 
epiphyseal separations in, 596 
great trochanter, 629, 631 
pathology of, 631 
symptoms of, 632 
treatment of, 632 
head, 593 

in hip dislocation, 693 
intercondyloid, 656 

complications of, 658 
diagnosis of, 659 
pathology of, 657 
prognosis of, 660 
treatment of, 660 
operative, 660 
Kocher's pertrochanteric, 629 

pathology of, 630 
lesser trochanter, 632 
causes of, 633 
symptoms, 633 
treatment, 635 
neck, 594 

at base, 601 
in children, 596 
complications of, 606 
diagnosis of, 614- 
extracapsular, 598, 601 
fibrous union in, 604, 616 
impaction in, 594 

treatment of, 607 
intracapsular, 598 
mechanism of, 599 
pathology of, 599 
prognosis of, 615 
repair of, 602 
results of, ()07 



872 



INDEX 



Femur, fractures of neck of, signs and 
symptoms of, 608 
treatment of, 616 

by abduction, 618 
Buck's extension, 617 
continuous extension, 

617 
Hodgen's splint, 617 
Liston's splint, 617 
operative, 623 

artificial impac- 
tion, 623 
by bone peg, 625 
by excision of 

' head, 626 
by nails, 624 
periosteal suture, 

626 
results of, 628 
simple replace- 
ment, 624 
technic of, 625 
Philips-Maxwell 

method, 621 
Rainey splint, 619 
suspension in children, 

621 
Thomas's splint, 619 
separation of "lower epiphysis, 
661 
causes of, 661 
pathology of, 662 
symptoms and di- 
agnosis, 663 
treatment of, 664 
shaft, 636 

causes of, 636 
complications of, 638, 641 
delayed union in, 647, 652 
non-union of, 639 
open, 648 
pathology of, 637 
prognosis of, 642 
symptoms and signs of, 

642 
treatment of, 644 
in children, 646 
operative, 648 

Codivilla's nail ex- 
tension, 653 
indications for, 

649 
Lambotte's 

method, 652 
Lane plate, 651 
Steinmann's nail 

extension, 654 
technic of, 650 
statistics of, 589 
supracondyloid, 656 
viabiHty of head, 595 
methods of measuring, 511 
Morris's bitrochanteric test, 613 
Nelaton's Hne, 612 
structure of, 591 
unequal lengths of, 611 



Fibrous union in fractures of neck of 
femur, 604, 616 
of tibia, 750 
Fibula, dislocations of, 810 
lower end, 812 
upper end, 810 

diagnosis of, 811 
treatment of, 811 
fractures of, 794 

diagnosis of, 794 
epiphyseal separation of, 795 
treatment of, 794 
upper end, 739 
osteotomy in ankle fracture, 794 
used as bone spHnt, 151 
First aid in reduction of fracture, 97, 

99 
Fluoroscopic control of fractures, 153 
Flying start mechanism of cervical frac- 
ture dislocations, 262 
Foot, dislocation of, mediotarsal, 852 
classification of, 852 
treatment of, 853 
subtalus, 849 

backward, 851 
diagnosis of, 851 
forward, 851 
inward, 850 
outward, 851 
prognosis of, 852 
treatment of, 851 
tarsal bones, 853 
supernumerary bones of, 823 
Football injuries of shoulder, 312 
Forearm bones, dislocation of, divergent, 
507 
lateral, inward, 505 
outward, 502 
fractures of, shaft and lower 
end, 454 
causes of, 455 
in children, 456 
pathology of, 457 
symptoms and 
diagnosis of, 
458 
treatment of, 460 
at wrist, 485 
lateral dislocations of, 502 
fractures of, supination in treatment 
of, 461 
use of intramedullary splints 
in, 462 
Fossae of skull, 184 

Fracture after removal of bone splint, 
151 
articular, 55 
of atlas, 262 
of axis, 267 
boxes, 116 

of calcaneus. See Calcaneus, frac- 
tures of. 
of carpal bones. See Carpal bones, 

fracture of. 
cause of, 35 

direct violence, 44, 46 



INDEX 



873 



Fractiu'e, cause of, disturbance of cal- 
cium equilibrium and, 37 
exciting. 44 

external influences in, 36 
functional, 35 
hereditary influence on, 35 
indirect violence, 44, 47 
influence of metabolism on, 37 
muscidar action, 45 
}3athological conditions and, 37 
personal tendency in, 35 
physiological, 35 
tumors, 37 
of cervical vertebra^, 261 
classification of, 53. Sec Pathology, 
of coccyx, 585 

comminuted. See Comminuted frac- 
tures, 
complications of, local, 68 
bloodvessels, 72 
callus, 73 

causes of, 75 
delayed union, 76 
excessive, 73 
fibrous union, 77 
non-union, 76 
painful, 73 
pseudarthrosis, 77 
weak, 75 
local gangrene, 72 
nerve, 72 

^'olkmann's ischemic con- 
traction, 69 
pathology of, 

69 
symptoms of, 

70 
treatment of, 
70 
and sequellae of, 62 

delirium tremens, 67 
fat embolism, 63 
general sepsis, 67 
neurasthenical condition, 

68 
postural and weight-bear- 
ing changes, 68 
pulmonary, 63 
tetanus, Ql 
of condyle of inferior maxifla, 225 
of coracoid process, 449 
of coronoid process, 227 
of costal cartilages, 331 
course of, 32 

blood changes in, 33 
callus formation in, 33 
delirium tremens in, 33 
fat embolism in, 33 
fever in, 33 
influences on, 34 
pulmonary congestion in, 33 
of cricoid cartilage, 350 
diagnosis of, 91, 95 

Roentgen-ray examination in, 
96 
in dislocatif)ii, 179 



Fracture and dislocations of sternum, 
345 
displacement of, 56 
angular, 57 
impacted, 57 
longitudinal, 57 
overriding, 57 
rotatory, 57 
spiral, 57 
transverse, 56 
of dorsal vertebra), 270 
etiolog}^ and mechanism of, 35 
of facial bones, 214 
of femur, 589 
of fibula, 794 
fixation of, 114 

indications for, 114 

methods of applying, 115 
use of sphnts in, 115 

types of dressing in, 
115 
of forearm bones, 441 
general mechanism of, 45 

analysis of forces, 45 
compressive and tensile 

stresses, 45, 46 
torsion, 45 

flexion and shearing 
stresses, 45 
of great toe sesamoids. See Sesa- 
moids, fracture of. 
gunshot, 60 
of humerus, 352 
of ilium, 586 
incomplete, 58 

depression and punctures, 58 
fissure, 58 
green-stick, 58 
of inferior maxilla, 223, 228 
of intramedullary bone splint, 151 
intra-uterine, 43 
true, 43 

medicolegal aspect of, 44 
of jaw, intracapsular, 226 
of laryngeal cartilage, 350 

and tracheal cartilages, 350 
of leg bones. See Tibia and Fibida, 

fractures of. 
of lumbar vertebra), 274 
of malar bone, 218 
malleolar, 31 
malposition in, 149 

operative treatment of, 149 
malunion of, 152 

operative treatment of, 152 
of metacarpal bones, 529 
of metatarsal bone. See Meta- 
tarsal bone, fracture of. 
methods of eliciting pain in, 91 
multiple, 60 
of nasal bone, 214 
non-union of, 32 
in open, 78 
obstetrical, 43 
of olef!ranon process, 441 
()[)en. See Open fractures. 



i 



874 



INDEX 



Fraotiu'e, open and closed, 59 
operated, 136 

Cook County Hospital, 136 

infection in, 136 
statistics of, 136 
of patella. See Patella, fractures of. 
pathological, 32, 36, 37 
actinomycosis and, 38 
bone cysts and, 38 
carcinoma and, 39, 42 
chronic esteomyelitis and, 38 
hypernephroma and, 42 
influence of breast cancer on, 41 
neurotrophic, 38 
sarcoma and, 39, 42 
pathology of, 53 
complete, 53 
oblique fracture, 53 
plane of, 53 
of soft parts, 61 

V-, Y-, and T-shaped fractures, 
53 
of pelvis, 570 
of phalanges of fingers, 534 

of foot. See Phalanges, frac- 
ture of. 
physiological, 33 
premature use of, 75 
of radius, head and neck, 450 
reduction of, 99 

anatomical, 100 
deformity after, 102 
disability after, 102 
early and late, 101 
epiphyseal separation in, 100 
factors favoring, 101 
obstructing, 101 
first aid in, 99 
immediate traction, 105, 108 

to disengage bone frag- 
ments, 108 
Gerster's turnbuckle 

in, 106 
Hawley table, 106 
Ridlon's apparatus, 
106 
means of, 103 

medicolegal aspect of, 99, 104 
near joints, 101, 102 
necessity for, 101 
non-operative, 100 
in open fractures, 102 
prolonged traction in, 110 
non-operative, 110 

Bardenheuer's ex- 
tension in, 110 
Buck's extension, 

110 
Hackenbruch's 
rods in, 110 
Hodgen's splint, 

110-112 
Thomas's splint 
in, 110 
operative, Codivilla's 
extension, 110 



Fracture, reduction of, prolonged traction 
in operative, 
Ransohoff's ex- 
tension in, 110 
Steinmann's ex- 
tension in,- 110 
relation of non-union to, 102 

soft parts to, 102 
Roentgen rays after, 103 
rules governing, 102 
types of spHnts used in, 99 
use of anesthesia in, 104 
of ether rausch in, 104 
of fluoroscope in, 103 
Wolff's law applied to, 100 
of -ribs, 331 

of rim of glenoid in shoulder dislo- 
cations, 416 
of sacrum, 584 
of scapula, 322 
separation of epiphysis, 55 
of sesamoid bones of thumb, 536 
of shaft of radius. See Radius, frac- 
ture of shaft of, 467 
of ulna. See Ulna, fracture of 
shaft of, 464 
of skull, 143, 184 
of spine, 143 
spontaneous, 36 
of superior maxilla, 220 
symptoms and signs of. ^ See Symp- 
toms and signs of fracture, 
of Talus. See Talus, fractures of. 
of tarsal cuboid bone. See Cuboid, 
fracture of. 
cuneiform bones. See Cunei- 
form bones, fracture of. 
navicular bone. See Navicular 
bone, fracture of. 
of thyroid cartilage, 350 
of tibia. See Tibia, fracture of. 
of tracheal cartilage, 350 
treatment of, 97 

American Surgical Association's 

report on, 121 
British Medical Association's 

report on, 121 
care of skin in, 129 
conclusions regarding operative 

interference, 122 
diagnosis before, 98 
first aid, 97 
fluoroscopic, 153 
hospitalization in, 98 
hydrotherapy in, 121 
ideal, 122 
immediate, 97 

infection in operated case, 136 
influence of age on, 98 
intramedullary pegs in, 134 
Lucas-Championniere's, 122 
massage in, 120 
dangers of, 120 
indications for, 120 
methods of giving, 120 
results obtained from, 120 



INDEX 



875 



Fracture, treatment of, medicolegal 
aspects of, 98 
operative, 123, 130, 137 
delaj'ed union in, 131 
end-results in, 131 
hemorrhage in, 146 
' indications for, 131 

infections in, 137, 142 
preparation for, 143, 144 
restoration of function in, 

131 
results in, 137, 142 
suture material used, 137 
table of cases, 138 
technic of, 137, 143 
time in hospital, 142 
passive movement, 120 

afterremoval of splints, 

12(5 
effect of, on joints, 

121 
rules of, in joint frac- 
tures, 120 
physiological position in, 104 
postoperative, 147 
reduction in, 99 
roentgenogram in, 98 
surgeon's limitation in, 98 

surroundings in, 130 
use of anesthesia in, 98 
of muscles in, 121 
of tuberosity of humerus in shoulder 

dislocations, 416 
types of, buckling, 49 
flexion, 47 
green-stick, 48 
shearing, 48 
spiral, 50 
torsion, 47, 49 
of ulna. See Ulna, fractures of. 
ununited, 77, 154 
of vertebrae, 243 
Fractured dislocation, 168 
Fragments, approximation of, 79 

in non-union, 79 
Fragilitas ossium, 37 
Function, loss of, 92 



Gallies's bone wedging in treatment of 

fracture of leg, 765 
Gangrene, following dislocation, 165 

resulting from fracture, 90 
Gerster's turnbuckle in reduction of 

fracture, 106 
Gibson's bandage, 229 
Gigantism, local 88 
Green-stick fracture, 48, 58 
Gunshot fractures, 60 

pathologj^ of, 60 
of skull, 209 
injuries of vertebrae and cord, 283 
of skuU, 185, 189 
of spinal cord, 277 



Habitual dislocations, 158, 162, ISO 
pathology of, 163 
treatment of, 180 
Hackenbruch's extension in reduction of 
fracture, 114 
development of, 114 
Hand and wrist bones, dislocations of, 

classification of, 543 
Haversian system, 22, 23 
Hawlev table m reduction of fracture, 

106' 
Head harness in treatment of cervical 

fracture-dislocation, 269 
Heidenhain's mass suture, 212 
Hematomyeha, 254, 255 

in dorsal fractures, 273 
Hematuria in spine fractures, 260 
Hemiplegia in fracture of vertebrae, 

256 
Hemoptysis in rib fracture, 335, 339 
Hemorrhage of cord in vertebral frac- 
ture, 254 
from ear in fracture of skull, 202 

jaw dislocations, 241 
in operative treatment, 146 
into spinal cord following fracture, 
257 
Heimequin's sign, 613 
Hernia of lung in rib fracture, 337 
Hexamethjdenamine, use of, in skull 

fractures, 208 
Hey-Groves's experiments on internal 

bone splints, 133 
Hip, anatomy of, 670, 671 
dislocations of, 670 
anterior, 685 

classification of, 686 
directly upward, 688 
infracotyloid, 691 
obturator, 689 
open, 687 
perineal, 692 
pubic, 686 

causes of, 686 
pathology of, 686 
symptoms of, 687 
treatment of, 687 
subspinous, 688 
thyroid, 689 

everted, 690 
treatment of, 691 
classification of, 673, 675 
complications of, 692 

fracture of femur, 693 

of pelvis, 694 
muscle tears, 692 
sciatic nerve injury, 693 
vessel rupture, 693 
double, 672 
function of Y-ligament in, 675, 

683 
mechanism of, 674 
old, 695 

reduction of, 695 



i 



876 



INDEX 



Hip, dislocations of, old, treatment of, 
operative, 695 
open, 673 
posterior, 675 

causes of, 675 

spontaneous, 676 
everted dorsal, 681 

diagnosis of, 682 
pathology of, 676, 678 
position of head in, 677 
shortening in, 680 
symptoms of, 679 
treatment of, 682 

Allis's method in, 683 
reduction experi- 
ments in, 683 
Bigelow's method in, 
684 
reduction experi- 
ments in, 683 
influence of Y-liga- 

ment in, 683 
Stimson's gravity 

method in, 685 
prognosis and after-treatment 

of, 694 
statistics of, 671 

in children, 672 
treatment of operative, 695 
variations of, 675 
joint, anatomy of, 589 

motions of, 671 
snapping, 162 
Hoaglund's scheme of trabecular systems 

in calcaneus, 814 
Hodgen's splint. 111, 112, 617, 645 
Horsley's bone wax, 212 
Howzell's pressure forceps, 212 
Humerus, anatomy of, 352 

dislocations of, at shoulder, 414 
epiphyseal centres of, 352 
fracture of, 352 

anatomical neck, 358 

treatment of, 361 
classification of, 357 
condyles, 407 
internal, 407 

pathology of, 408 
treatment of, 409, 410, 

411 
statistics of, 410 
dislocations of upper end, 
378 
treatment of, 379 
examination in, 354 
greater tuberosity, 372 

diagnosis of, 376 
pathology of, 376 
statistics of, 373 
treatment of, 377 
with dislocation, 374 
impaction of anatomical neck, 
360 
treatment of, 361 
lower end of, 393 

capitelhim, 413 



Humerus, fracture of lower end of, 
degree of flexion for 
dressing, 407 
dicondylar, 399 

diagnosis of, 401 
displacement of, 

400 
pathology of, 400 
differential diagnosis, 

403 
displacement in, 394 
epitrochlear, 413 
examination of, 394 
infracondylar, 399 
mechanism of, 393 
old cases, 406 

treatment of, 
406 
open, 413 
pathology of, 412 
Posadas's type, 390 
separation of epiphysis, 

412 
supracondylar, 396 
carrying angle in, 

398 
causes of, 397 
symptoms of, 396 
T-fractures, 401 
treatment of, 404, 412 
trochlea, 413 
measurements in, 354 
mechanism of, 357 
ruler test, 354 
shaft, 379 

complications of, 381 
gunshot, 387 
musculospiral paralysis, 
381,382 
indication for oper- 
ation, 382 
prognosis of, 382 
treatment of, 382 
pathology of, 380 
pseudarthrosis in, 387 
treatment of, 388 
treatment of, 383 

intramedullary splint, 

385 
operative, 384 
ununited, 386 
shaft, Volkmann's ischemic con- 
traction in, 384 
statistics of, 357 
separation of upper epiphysis, 
371 
in connection with 
birth palsies, 
372 
treatment of, 372 
surgical neck of, 361, 365, 371 
displacement of, 366 
nerve and vessel in- 
volvement, 365 
non-union in, 361, 369 
old cases, 364 



INDEX 



877 



Humerus, fracture of surgical neck of, 
operative results in, 
362 
prognosis of, 371 
statistics of. 363 
treatment of, 364, 368 
abduction, 369 
operative, 365, 370 
Hyoid bone, anatomy of, 343 

fractures and dislocations of, 
343 
reduction of, mechan- 
ism of, 345 
tracheotomy in, 345 
treatment of, 344 
Hyperfiexion in treatment of condylar 
fracture of humerus, 410 



Ileus, paralvtic, following rib fracture, 

335 
lliotrochanteric ligament, 670 
Ilium, fracture of, 586 

anterior spine, 587 
sprain, 587 
treatment of, 588 
Immobilization, 135 
effect of, 136 
with internal splints, 135 
Impacted fractures of anatomical neck 

of humerus, 360 
Impaction in neck of femm-, treatment 
of, 607 
value of, 594 
Incomplete fractures, 58 
Incontinence of urine following fracture 

of vertebrae, 260 
Infection in bone, 29 

effect on callus, 29 

on small fragments, 30 
following dislocation, 167 
Inferior maxilla, dislocations of, 236 
arthroplast}' in, 240 
backward, 240 
differentiated from frac- 
ture, 238 
forward, 236 
habitual, 239 
inward, 242 
outward, 242 
recurrent forward, 240 
statistics, 236 
treatment of, 238 

McGraw's method,239 
operative, 239 
unilateral, 238 
upward, 242 
fracture of, 223, 228 

classification of, 224 
condyle of, 225 
pathology of, 224 
statistics in, 223 
treatment of, 228 
Infra-<jrljital nerve in malar fracture, 219 



Infra-orbital nerve in superior maxilla 

fracture, 219 
Injection treatment of habitual disloca- 
tion, 181 
Inlay bone grafts, 27 
Instruments for bone surgery, 156 
Allen's plate, 157 
Bartlett's clamp, 146 
chisels, 145 
Coerr's lever for reduction, 

146 
drills, 145, 156 
electric saw, 156 
Hawley table, 156 
Lambotte's clamp, 156 
Morrison's clamp, 154 
reamers, 156 
rotatory saw, 156 
Simmons's clamp, 154 
Intercostal artery, 335 

injuries of, in rib fracture, 335 
hemorrhage, 341 
nerve, 335 

injuries of, in rib fracture, 335 
Interdental splints, 222 

in jaw^ fracture, 226 
Kingsley's, 234 
permanent, 233 

temporary, in jaw fracture, 232 
Internal splints in open fractures, 125- 

128 
Interosseous membrane, ossification of, 

in forearm, 459 
Intracapsular fracture of jaw, 226 
Intramedullary bone grafts, 27 
splints, 27, 142 

forearm fractures, 462 
fracture of, 151 
in fracture of leg, 762 
precaution of application, 

152 
results in, 142 
in ununited fracture of 
shaft of humerus, 389 
pegs, 134 

bone, 134 

metal, 134 

insertion into medullary cavity, 

149 
site and technic of obtaining, 

149 
technic of removal, 149 
Irradiation theory of skull fracture, 186 
Ivory pegs, 152 

sterilization of, 152 
plates, application of, 146 



Jack-knife mechanism in fracture of 

vertebra?, 254 
Jaw. See Superior and inferior maxilla. 
Joints, 161 

ball-and-socket, 161 
! elbow, 353 



878 



INDEX 



Joints, fracture of, 31 

callus formation in, 32 
reduction of, 101 

metacarpal phalangeal, 161 

phalangeal, 161 

sternoclavicular, 305 

snapping, 162 

trigger, 162 



Kanavel's splint in fractures of leg, 751 
Kangaroo tendon in acromioclavicular 
dislocation, 318 
in fracture of clavicle, 303 
Kienboch's disease of carpal bones, 527 

of lunate bone, 547 
Kingsley's splints in fracture of jaw, 234 
Knee, dislocations of, 797 
backward, 800 

pathology of, 801 
symptoms of, 802 
treatment of, 803 
forward, 797 

complications of, 799 
pathology of, 797 
symptoms of, 799 
treatment of, 800 
lateral, 804 

inward, 804 
outward, 804 

symptoms of, 804 
treatment of, 805 
rotatory, 805 

incomplete, 806 
treatment of, 806 
statistics of, 797 
subluxations, 806 
joint, anatomy of, 590, 722 
crucial ligaments of, 735 
hemarthrosis in patellar frac- 
ture, 712 
incisions for exposing, 715 
lavage in, 712 
ligaments of, 733 
rupture of capsule in patellar 

fracture, 702 
semilunar cartilages in, 734 
Knock-knee in connection with disloca- 
tion of patella, 729 
Kocher's method of reduction of shoulder 
dislocations, 423 
operative method in treatment of 

patella dislocations, 730 
pertrochanteric fracture of femur, 
629 



Lambotte's clamp, 156 

objections to, 157 

plates, 127 
Lamellae of bone, 19 
Laminectomy, 143 

effect on spinal cord, 255 



Laminectomy, indications for, 281 
late, 282 
mortality in, 282 
prognosis in, 281 
technic of, 284 

Allen's procedure, 284 
osteoplastic exposure, 285 
Lane plates, 26, 134, 142 

application of, 146 
delayed and non-union follow- 
ing use of, 135 
effect on callus, 26 
experiments on retention force 

of screws in, 135 
external fixation in connection 

with, 26, 27 
in fractures of clavicle, 303 
hindrance to union in fracture, 

154 
in leg fractures, 756, 757 
mechanically inefficient, 135 
relation of, to periosteum, 134 
use of, in non-union, 153 
Laryngeal cartilage, fracture of, 350 

tampon, use of, 351 
Lever action in shoulder dislocation, 415 
Lexer's theory, 28 

in bone regeneration, 28 
Ligamentoplasty in acromioclavicular 

dislocation, 318 
Ligaments of elbow-joints, 353 

influence of, on dislocation, 160, 161 
role of, in reduction of dislocation, 
176 
Ligatures, use of, 146 
Limb, avulsion of, in dislocation, 179 
Liston's splint, 616 
Local anesthesia, use of, in reduction of 

fracture, 104 
Loher's splint, 232 
Ludloffsche's sign in fracture of lesser 

trochanter of femur, 635 
Lumbar puncture in skull fracture, 195, 
207 
in vertebral fracture, 260 
vertebral fracture-dislocations, 274 
Lunate bone, fracture of. See Carpal 
bones, fractures of. 
volar dislocations of, complete, 
550 
double, 551 
methods for roent- 
genogram in, 551 
operative treatment 

of, 553 
prognosis of, 551 
symptoms of, 550 
treatment of, 552 



M 



Mace WEN on regeneration of bone, 21 
Madelung's deformity, 540 
Malar bone, anatomy of, 218 
fracture of, 218 



INDEX 



879 



Malar bone, fracture of, antrum involve- 
ment in. 220 
infra-orbital nerve involve- 
ment in, 219 
svmptoms and diagnosis 
' of, 21S 

treatment of, 219 
Malgaigne's method of reducing 'shoulder 

dislocations, 425 
Malleolar fractiu-es, callus formation in, 
31 
nail repair m, 31 
results in. 31 
Malunion of caUus. So 

operative treatment of, 149 
IManipLilation in treatment of disloca- 
tion, 175 
Manubrium, fractiu-es of, 347 
Massage after dislocation, 183 
Matas's splint, 235 
]\Iaxillarv fracture, wiring of teeth in, 

221 
iMechanism of wrist movements and 

injuries, 543 
Mediastinal abscess after sternal frac- 
ture, 349 
Medicolegal aspect of fracture of ankle- 
joint, 782 
Mediocarpal dislocations and fracture- 
dislocations, 542 
Mediotarsal joint, dislocation of, 852 
^Medullary bone plug, 24 

cavity, reestablishment of, 
24 
canal in vertebral fractures and dis- 
locations, 247, 248 
cavity, reaming of, 149 
plug, 79 
Metacarpal bones, fracture of, 529 

Bennett's fracture, 530 

treatment of, 533 
epiphyseal separations in, 

530 
results of, 532 
statistics of, 529 
symptoms and diagnosis 

of, 531 
treatment of, 532 
phalangeal dislocations of fingers, 
566 
treatment of, 567 
of thumb, 561 
anterior, 566 
lateral, 566 
posterior, 561 

complete form, 

562 
incomplete form, 

564 
treatment, 564 
joints, mechanism of disloca- 
tion of, 161 
Metatarsal bones, dislocation of, 859 
causes of, 859 
divergent, 861 
first metatarsal, 860 



INletatarsal bonos, dislocation of, statis- 
tics of, 859 
symptoms of, 860 
total, 861 
fractures of, 831 
causes of, 832 
classification of, 832 
diagnosis of, 834 
epiphj^seal separation of, 

833 
infraction, 834 
open, 835 

treatment of, 833, 835 
Metatarsophalangeal dislocations, 862 
Michel clips, 147 
Mickuhcz's method of patellar suture, 

717 
Mixter-Osgood treatment of cervical 

fracture-dislocation, 270 
Mobilization, efTect of healing of frag- 
ments, 136 
Modelling wax, 222 

in jaw fracture, 232 
Morris's bitrochanteric test, 613 

fluoroscopic pinning of fractures, 153 
Morrison's clamp, 154 
Mouth irrigation in jaw fractures, 228 
Multiple dislocations, 158 

fractures, 60 
Muscle spasm in dislocation, 174 

transplantation in shoulder disloca- 
tion, 437 
Muscular action cause of dislocation, 161 

contraction, tetanic, 162 
Musculospiral paralysis following frac- 
ture of shaft of humerus, 381, 382 
MyeHtis, 261 

Myositis ossificans in elbow dislocation, 
494 
traumatic, 24 



N 



Nails, 152 

Nares, infection of, 215 

occlusion of, 215 
Nasal bone, anatomy of, 214 
fracture of, 214 

indications for operation in, 

217 
pathology of, 214 
prognosis of, 217 
symptoms of, 216 
treatment of, 217 
hemorrhage in fracture of skull, 202 
septum, 215 

deflection of, 215 
Nathan Smith's sphnt, 116 
Navicular bone, dislocation of, 853 

fracture of, 829 
Necrosis in regeneration of bone, 31 
N^laton's fine, 612 
Nerve injury in dislocation, 166, 179 
in elbow dislocations, 494 
in radial dislocation, 509 



sso 



INDEX 



Nerve injury in shoulder dislocations, 
418 
in upper humeral fractures, 380 
Neurotrophic fracture, 38 
Nichols and Smith's dressing for disloca- 
tion of clavicle, 316 
Non-union of callus, 32, 76 

effects of movement on, 78, 79 
following use of Lane plates, 135 
of fracture, 32, 76 
in open fractures, 78 
Nutrient artery, effect of, on regenera- 
tion, 23 



Oblique fracture, 53 

Occlusion of nares, 215 

Olecranon process, fracture of. See 

Ulna, fracture of. 
Open and closed fractures, 59 
dislocations, 158 

pathology of, 166 
of shoulder, 420 
treatment of, 167 
fractures, autotransfusion in, 124 
bone repair m, 29 
callus formation in, 29, 31 
causes of, 123 

internal, 59 
effect of infection on, 29 
first aid, 123 
hemorrhage in, 124 
immediate fixation of, 127 
indications for amputation in, 

124 
infection in, 30, 123-125 
operations on, 128 
pathology of, 59 
reduction of, 102, 124 
resistance against infection, 30 
results in, 127 
of ribs, 334 
shock of, 30 
statistics of, 127 
treatment of, 123, 125 
final, 128 

Lambotte's plates in, 127 
of shock in, 125 
technic of first aid, 125 
use of internal splints in, 
125 
Os calcis, accessory, 823 
intercuneiform, 823 
intermetatarsum, 823 
peroneale, 823 
tibiale externum, 823 
trigonum, 823 
vesalii, 823, 833 
Ossification of foot bones, 814 

of interosseous membrane in the 
forearm, 459 
Osteoblasts, 21, 22 
Osteogenesis imperfecta, 37 
Osteomalacia, 37 



Osteoplastic flaps in skull fracture, 206 
Osteopsathyrosis, 37 
Osteotomy of fibula in ankle fracture, 
794 
in old shoulder dislocations, 437 
in treatment of dislocation of 

patella, 729 
in unreduced dislocations, 182 



Pain in dislocation, 174 
Palate, injuries to, 222 
Paralysis, bulbar, in bursting skull frac- 
tures, 203 
following lumbar fracture disloca- 
tion, 278 
vertebral fracture, 259 
Patella, complete removal of, 720 
dislocations of, 722 

anatomy of knee-joint, 722 

median patellar 
ligament, 722 
causes of, 723 

congenital, 723 
recurrent, 723 
classification of, 723 
diagnosis of, 727 
old, 728 

treatment of, 728 
pathology of, 724 
backward, 725 
complete rotation, 724 
double, 725 
median, 725 
recurrent, 725 
prognosis of, 732 
symptoms and signs, 725 
treatment of, 727 
operative, 729 

capsular suture, 730 
Kocher's, 730 
muscle plastics, 731 
osteotomy, 729 
patellar tendo plasty, 
731 
fractures of, 697 
causes of, 697 
course of, 709 

displacement of fragments, 699 
double, 710 
old, treatment of, operative, 

721 
open, 706 
pathology of, 698 

capsular rupture in, 702 
comminuted, 699 
congenital defects of, 703, 

704 
fibrous union in, 705 
functional results, 705 
longitudinal, 698 
non-development of, 703 
oblique, 698 
ossification of, 703 



INDEX 



881 



Patella, fractiu'es of, pathology of, 
quadriceps muscle inser- 
tion in, 703 
transverse, 698 
refracture of, 710 
causes of, 710 
resultant deformities after, 705 
statistics of, 697 
symptoms and diagnosis of, 
707 
differential, 708 
Dreyer's sign, 708 
treatment of, 711 

conditions required in, 711 
operative, 712 
open, 713 

after-treatment 

in, 718 
Andrews's imbri- 
. cation, 718 
bone transplanta- 
tion in, 720 
contra-indications 

for, 714 
removal of patella, 

720 
statistics of, 714 
suture methods 
and material, 
716 
technic of, 715 
subcutaneous method, 
713 
Patholog}' of fracture, 89 

bloodvessel complications, 90 
gangrene, 90 
embolism, 90 
joint compHcations, 89 
contraction, 89 
fixation, 89 
hemarthrosis, 89 
malalignment, 89 
suppurative, 89 
traumatic, 89 
muscle and soft parts, 90 
of unreduced dislocation, 169 
Peckham's bandage, 298 
Pelvis, anatomy of, 570 

dislocation of ilium, 580 
fracture of, 570 

acetabulum, 580 
bladder involvement in, 575 
causes of, 572 
coccyx, 585 
complications, 575 
course and prognosis, 578 
double vertical, 574 
in hip dLslocations, 694 
ilium, 586 
Malgaigne's, 574 
patholog\^ of, 572 
sacrum, 584 

separation of sacro-iliac joint, 
576 
of symphysis, 576 
statistics of, 571 

56 



Pelvis, fracture of, symptoms and diag- 
nosis, 577 
treatment of, 578 
urethral involvement in, 575 
Pencil pressure to elicit pain in fracture, 

91 
Pericardial rupture in sternal fracture, 

347 
Perihmar dorsal dislocation of hand, 546, 

549 
Periosteum, bridge of, 22 
in callus formation, 22 
effect of infection on, 30 
formation of, 20 
function of, 20, 22 
histology of, 20 
in rib fracture, 333 
in sternal fractiu'e, 347 
Phalangeal joints, mechanism of tlislo- 

cation of, 161 
Phalanges of fingers, fracture of, 534 
treatment of, 535 
of foot, dislocation of, 862 
treatment of, 862 
fracture of, 835 

treatment of, 837 
PharjTigeal palpation of cervical frac- 
tures, 262 
Philips-Maxwell method of treatment on 

fractures of neck of femur, 621 
Plaster-of-Paris bandages, 118 
encasements, 118 

use of metal splints 
with, 118 
preparation and applica- 
tion of, 118 
splints, 117 

encasements or casts, 117 
indications for 

removal of, 118 
methods of appli- 
cation, 117 
as moulded splint, 117 
Plates, bone, 146 
ivory, 146 
Lane, 146 

use of, in malunion, 153 
Pleura, laceration of, in rib fracture, 335 
Pleural injuries, 292 

in sternal fracture, 347 
Pleuritis following rib fracture, 335 
Pneumonia, following spinal fracture, 
278 
in spinal fractures, 260 
Pneumothorax in rib fracture, 342 
Poliomj^elitis, efifect of, on bone, 19 
Popliteal vessels, injury of, in knee dis- 
locations, 799 
Posterior interosseous nerve injury in 

radial dislocation, 509 
Postoperative treatment, 147 
Presternal clavicular dislocations, 305 
Priapism in spinal fracture, 260 
Provisional callus, 24 
Pseudarthrosis, treatment of, 154 

intramedullary sj)Hnt in, 154 



SS2 



INDEX 



Q 



QiTADRK'EPs extensor muscle, relation to 
dislocation of patella, 724, 727 



R 



Radial nerve injury in fractures of the 
radius, 454 
in radial dislocation, 509 
head, position of, 356 
Radius, dislocation of, 509 
backward, 512 
forward, 510 

pathology of, 511 
treatment of , 511 
head, subluxation, 515 

symptoms and diag- 
nosis, 516 
treatment of, 516 
injury to radial nerve in, 509 
outward, 513 
pathology of, 509 
fracture of, Colles's, 471 
head and neck, 450 

causes and pathology, 

of, 450 
diagnosis of, 454 
treatment of, 454 
shaft, 467 

pathology of, 468 

in relation to pronator 
teres muscle, 469 
symptoms and diagnosis 

of, 469 
treatment of, 470 
styloid process, 485 
resection of head in dislocation, 511 
Railroad spine, 253 

splints, 116 
Rainey spUnt, 619, 645 
Ransohoff's extension in reduction of 
fracture, 110 
treatment in fracture of femur, 
656 
Recumbent treatment in fracture of 

clavicle, 295 
Recurrent dislocation, 163 
Reduction of dislocation, 176 
obstacles to, 176 
operative, of old shoulder disloca- 
tions, 438 
by simple replacement, 153 
Reflexes in vertebral fracture, 273 
Refracture through callus, 76 
Regeneration of bone, 20 

after removal of bone splint, 151 
bone fragments in, 24 
definitive callus, 24 
effect of Roentgen rays on, 24 
influence of nutrient artery on, 

23 
necrosis in, 23, 31 

medullary plugs in, 24 
of cord, after fracture, 277 



Repair of dislocation after reduction, 168 

pathology of, 168 
Replacement, simple operative, 153 
Reposition of fragments, 135 
Rib cartilages. See Costal cartilages, 
dislocation of, 340 

separation of cartilage, 341 
treatment of, 340 
Ribs, fracture of and dislocation of, 331 
anatomy of, 331 
. causes and statistics of, 
331 
multiple, 333 
pathology of, 332 
open, 334 

complications of, 334 
operative treatment of, 341 
Rickets, 37 

fracture and, 38 
Ridlon's apparatus in reduction of frac- 
ture, 106 
Rochet's operation for ankylosis in jaw 

dislocation, 241 
Roentgen-ray examination in diagnosis 

of fracture, 96 
Roentgenogram, medicolegal aspect of, 
104 
in reduction of fracture, 103 
in skull fracture, 184 
in treatment of fracture, 98 
Ruler test in fracture of humerus, 354 
Rupture of bloodvessels in dislocation, 
178 
of diaphragm in rib fracture, 338 



Sabotte's clamps in leg fractures, 759 
Sacro-iUac joint, lesions of, 579 
subluxations of, 580 
strain, 578 
Sacrum, fractures of, 584 
Sadler's felt used as pad, 179 
Sarcoma of bone, 87 

relation of, to fracture, 42 
to trauma, 42 
Sayre's dressing, 299 
Scalp wounds in skull fracture, 198 
Scaphoid. See Navicular bone, 829 
Scapula, fracture of, 322 
acromion, 324 

differentiation of, 327 
epiphyseal separation, 325, 

326 
sprain fracture, 325 
whole process, 326 
anatomy of, 322 
angles, 330 
of body, 322 

treatment of, 324 
coracoid, 328 
neck and glenoid cavity, 329 

treatment of, 330 
of spine, 324 
statistics of, 322 



IXDEX 



ssn 



Scapula, fracture of, s^^Tlptoms and 
diagnosis of. 323 
treatment of, 327 
Sclilatter's disease, 739 

differentiated from Schlatter's 
sprain, 739 
sprain, in fracture of tibia, 737 
Sciatic. nerve injury in hip dislocations, 

693 
Screws, absorption of bone, 26 

in Lane plates, 135 
Semilunar cartilages, dislocation of, 807 
anatomy of, 807 
diagnosis of, 808 
pathology of, 807 
sj^mptoms of, 808 
treatment of, 809 
operative, 810 
reduction of, 809 
injury of, in knee dislocations, 
799, 806 
Senn's splint, 618 

Sesamoid bones of thumb, fractures of, 
635 
of great toe, fractures and disloca- 
tion of, 837 
diagnosis of, 838 
treatment of, 838 
Sharpey's fibers, 20 
Shock caused by traction, 154 

open fractures, 125 
Shoulder, dislocation of, 414, 420 
anatomy of. 414 
anterior, 415, 420, 425, 428 
intracoracoid, 428 
results, 426 

complicated cases, 426 
subclavicular, 428 
subcoracoid, 415 

complications of, 418 
patholog}' of, 416 
subluxations, 427 
symptoms and diagnosis, 
'420 
treatment of, 422 

after reduction, 425 
anesthesia, 423 
methods of reduction, 
423 
capsulorrhaphy, EhrHch's and 
Clairmont's operation, 
436 
in epileptics, 436 
results of, 436 
downward, 431 

luxatio erecta, 432 
subglenoid, 431 
habitual, 433 
landmarks of, 414 
old, 437 

non-operative treatment 

of, 438 
obstacles to reduction of, 

437 
osteotomy in, 437 
treatment of, operative, 438 



Shoulder, dislocation of, old, treatment 
of, operative, results of, 439 
posterior, 429 

pathology of, 430 
subacromial, 429 
subsphious, 429 
sj-mptoms of, 430 
treatment of, 430 
recurrent, 433 

avoidance of, 434 
causes, 433 
treatment of, 434 
operative, 435 
statistics and classification of, 

414 
upward, 432 
movements, 305 

subluxation of, anterior, pathology 
of, 428 
treatment of, 428 
Silver-fork deformity in CoUes's fracture, 

480 
Simmons's clamp, 154 
Sinuses of skull in nasal fracture, 216 

in relation to fracture, 188 
Skull, anatomy of, 184 
bloodvessels of, 184 
fossae of, 184 

fractures of, 143, 184, 185, 193 
Aran's theory, 186 
aphasia in, 196 
bhndness in, 196 
blood-pressure in, 198 
bursting, 191, 198 

blood-pressure in, 198, 204 
brain damage in, 198, 203 
bulbar paralysis in, 204 
cerebrospinal fluid in, 198 
coma in, 199 
concussion in, 198 
convulsions in, 203 
eye-ground findings, 203 
fever in, 198 
hemorrhage from, 202 
indication for operation, 

209 
involvement of cranial 

nerves in, 203 
leukocytosis in, 198 
meningeal hemorrhage in, 

199 
muscle tone in, 204 
nasal fossa? in, 201 
pathology of, 191 
and radiating, 185, 191 
symptoms of, 198 
use of the roentgenogram 
in, 204 
cerebral pressure in, 196 
cerebrospinal fluid in, 193 
classification of, 184 
contrecoup theory, ISO 
deafness in, 196 
diabetes in, 196 
drainage in, 197, 20S, 209 
ej)ilepsy follf)wing, 20(j 



884 



INDEX 



Skull, fractures of, experiments on, 187 

fossal, 187 
frequency of, 187 
gunshot, 185, 189, 209 
anesthesia in, 209 
Horsley's experiments on, 

190 
indication for operation, 

209 
pathology of, 190 
theories of, 191 
hemorrhage in, 196 
indented, 185 

indications for operation in, 208 
irradiation theory, 186 
lumbar puncture in, 207 
mechanism of, 185 
pathology of, 188 
prognosis of, 204 
punctured, 185, 188, 190, 197 
cases not followed by ab- 
scesses, 190 
symptoms of, 197 
use of roentgenogram in, 
197 
results in, 143 
secondary changes in, 197 
statistics of, 187, 188 
treatment of, 206 
use of roentgenogram in, 184 
glenoid cavity, in relation to jaw 
fracture, 226 
Smith's, Nathan R., splint, 644 
Snapping callus, 87 
hip, 162 
joints, 162 
Sneezing as cause of sternal injuries, 346 
Souttar's plate in leg fractures, 758 
Spinal cord, anatomy of, 255 

complete lesion, symptoms of, 

280 
decompression of, 256 
destruction of, 283 
drainage of, 256 
effect of laminectomy on, 255 
gunshot injuries of, 283 
gunshots of, 277 
hematomyelia in, 255 
hemorrhage, 254 

following fracture, 257 
incomplete lesions of, 278 
medicolegal cases, 278 
partial lesions, 281 

experiments on, 281 
regeneration of, 255 
repair of, 255 
fluid in vertebral fracture, 260 
puncture, 285 
Spine. See Vertebra?, 
fracture of, 143 
results in, 143 
Spiral fracture, mechanism of, 50 
Splints, aluminum, 116 
ambulatory, 118 

bone, fracture of tibia after removal 
of, 151 



Splints, coaptation, 115 
Cobb's, 217 

Dupuytren's, in ankle fracture, 781 
Englemann's, 117, 647 
external, after operation, 147 

internal, 156 
Hey-Groves's experiments on in- 
ternal bone, 133 
Hodgen's, 112, 617, 645 
indication for changing, 147 

for removal, 147 
inspection of, 147 
interdental, 222, 229, 231 

permanent, 233 
internal, 133 

experimental study of, 133 
external fixation in connection 

with, 133 
indications for, 143 
infection surrounding, 148 
intramedullary, 142 

nails and screws, 142 
plates, 142 
time in hospital, 142 
irritative effect on bone, 134 
ivory pegs, 152 

sterilization of, 152 
nails, 152 

rate of repair with, 133 
relation of periosteum to, 133 
removal of, indication for, 148 

technic of, 148 
selection of cases for, 143 
Walton's operative indications, 
143 
intramedullary bone in fracture of 
leg, 762 
site and technic of obtaining, 

149 
technic of, 149 
Kanavel's in fracture of leg, 751 
Kingsley's, 234 
Liston's, 616 

Loher's, in wiring teeth, 232 
Matas's, 235 

Nathan R. Smith's, 116, 644 
in non-union of callus, 131 
plaster-of-Paris, 117 
railroad, 116 
Rainey's, 619, 645 
Senn's, 618 
Thomas's, 117, 619 
Volkmann's sliding, 116 
wire, 116 
wooden, 115 
Spontaneous dislocations, 158 

fracture, 36, 37 
Sprain fracture of vertebra), 273 
Sprains, 158 

of back, 252 
Staples, 156 

Statistics of dislocations, 159 
Steinmann's extension, 56 

in reduction of fracture, 110, 114 
development of, 114 
nail extension in leg fractures, 759 



INDEX 



885 



Steinmann's nail extension in treatment 
of fractures, 654 
of fracture ojf femur, 
654 
Sternoclavicular joint, 305 
anatomy of, 305 
ligaments of, 305 
shoulder movements, 305 
Sternum, anatomy of, 345 

ensiform process, dislocation of, 348 
fracture of, body, 34S 
course of, 349 
and dislocation of, 345 
causes of, 345 
complications of, 347 
emphysema, 347 
pathology of, 346 
ensiform process, 348 
gunshot, 349 
manubrium, 347 
open, 349 

symptoms and diagnosis of, 348 
treatment of, 349 
Stiff neck in cervical fractures and dis- 
locations, 265 
differentiated 
from torticollis, 
266 
Stimson's gravity method in treatment of 
hip dislocation, 685 
method of reducing shoulder dis- 
locations, 425 
Stromeyer cushion, 361 
Subconjunctival hemorrhage in fracture 

of skull, 202 
Subcutaneous hemorrhage in fracture of 

skuU, 202 
Subluxation, 58 

of atlas, 262, 264 
of axis, 266 
repeated, 162 

of the shoulder, anterior, 427 
Subtalus dislocations, 849 
Superior maxilla, fracture of, 220 

nerve involvement in, 221 
svmptoms and diagnosis of, 
'221 

treatment of, 221 
Supination in treatment of forearm 
fractures, 461 
of radial fractures, 469 
Supracondylar osteotomy in humeral 

fractures, 406 
Surgical emphysema, 335 

treatment of, 342 
SjTidesmopexv in acromioclavicular dis- 
locations, 3"i8 
Syj)hin.s of bone, fracture and, 38 
Syphilitir- frar-turo. 38 



Tabetic fracture, 38 
Talus, dislocations of, 845 
backward, 847 



Talus, dislocations of, classification of, 
846 
forward, 846 
inward, 847 
open, 849 
outward, 846 
rot at or V, 848 
total, treatment of, 848 
fractures of, 823 

anatomy of, 823 
classification of, 825 
pathology of, 825 
posterior process, 827 
symptoms and diagnosis of, 
■ 826 

treatment of, 827 
Tarsal bones, dislocation of, 853 

calcaneus, 846, 849, 853 
cuneiform, 859 
navicular, 853 

anatomj' of, 854 
double, 856 
statistics of, 854 
treatment, 858 
Temporomaxillary joint dislocations, 241 
complications of, 241 
ankylosis, 241 
asphyxia, 241 
deafness, 241 
hemorrhage from ear, 
241 
in jaw dislocations, 241 
fracture, 226 
Tenotomy of calcaneous tendon in leg 

fractures, 752 
Thomas's damming method in treatment 
of non-union of callus, 83 
pounding method in non-union, 152 
splint, 110, 113, 117, 619 
in leg fractures, 756 
WTench in dislocation, 179 
Thyroid cartilages, fractures of, 350 
Tibia, anatomy of, 733 

development of upper epiphj'sis, 
737 
crucial ligaments at upper end, 735 
fracture of, 733 

intercondyloid eminence, 734 
lipping, 771 

lower articular surface, 
781, 788 
malleoli, 771 

after-treatment of, 785 
causes of, 771 
complications of, 772 
aversion, 778 
inversion, 785 

pathology of, 786 
treatment of, 788 
mechanism of, 792 
old, 794 
open, 775 
pathology of, 771 
prognosis of, 780 
talus, disi)laconient of, 789 
treatment of, 781, 793 



886 



INDEX 



Tibia, fracture of, malleoli, treatment 
of, medicolegal aspects of, 
782 
Pott's 771, 778 

statistics of, 778, 790 
shaft, 746 

causes of, 746 
complications of, 750, 764 
non-union in, 764 

treatment of, 765 
Bier's method, 

765 
inlay graft, 765 
displacements of, 749 
fibrous union in, 750 
with fibular fractures, 748 
flexion, 749 
longitudinal, 748 
nutrient artery in, 749 
oblique, 749 
open, 763 

treatment of, 763 
prognosis of, 766 
shearing, 748 
spiral, 749 

causes of, 749 
symptoms and signs of, 

751 
torsion, 749 
transverse, 747 
treatment of, 751 

by Kanavel splint, 753 
by mechanical exten- 
sion, 754 
operative, 756 
clamps, 759 
intramedullary 

splint, 762 
Lane plate, 757 
Souttar plate, 758 
Steinmann's nail 

extension, 759 
wire, 759 
by tenotomy of cal- 
caneous tendon, 752 
spine, 734 

avulsion of, 735 
classification of, 735 
external tubercle of, 736 
in knee dislocations, 799 
relation of crucial liga- 
ments to, 735, 736 
with rupture of crucial 

ligaments, 737 
treatment of, 737 
sprain, 734 
supramalleolar, 746 
tubercle, 737 

Schlatter's sprain, 737 
symptoms and signs of, 

738 
treatment of, 739 
upper end, 739 

causes of, 739 
course and prognosis, 
of, 744 



Tibia, fracture of upper end of. diagnosis 
of, 745 
disulacement of, 742 
with fibular fracture, 

741 
open, 745 
treatment of, 744 
tuberosity of, 740 
vessel injury in, 743 
lower epiphysis, separation of, 768 
diagnosis of, 770 
interference with 

growth, 768 
treatment of, 770 
semilunar cartilages at upper end, 

734 
upper epiphysis of, separation of, 
746 
Torsional fracture, mechanism of, 50 

rules governing, 52 
Total dislocation of clavicle, 320 
Trachea, rupture of, in cartilage fracture, 

351 
Tracheal cartilages, fracture of, 350 
Tracheotomy in cartilage injury, indi- 
cation for, 351 
Traction causing shock, 154 
Codivilla's extension, 156 
immediate, 108 
prolonged, 110 
Steinmann's extension, 156 
in treatment of dislocation, 175 
Transplantation of bone, 27 
Transplants, fate of, 27 
Trapezoid ligament in clavicular dislo- 
cations, 310 
fracture, 291 
Traumatic asphyxia in rib fracture, 338 

myositis, 25 
Triceps muscle, relation to elbow frac- 
ture, 404 
Trigger joints, 162 
Tuberculous fracture, 38 
Tumors in callus, 87 



Ulna, dislocation of alone, 514 
backward, 514 
forward, 515 
lower end, backward, 735 

treatment of, 538 
forward, 539 

treatment of, 540 
Madelung's deformity 
540 
pathology of, 

541 
treatment of, 
542 
with olecranon fracture, 444 
fracture of, 441, 449 

coronoid process, 449 

causes and pathology 
of, 449 



INDEX 



887 



Ulna, fracture of, coronoid process, 
symptoms and diag- 
nosis of. 450 
treatment of, 450 
olecranon process, 441 

causes and pathology 

of, 442 
epiphyseal separation 

of, 448 
non-union in, 445 
repaii- of. 445 
symptoms and signs 
' of, 444 

treatment of, 446 
operative, 447 
shaft, 464 

in connection with radial 
dislocation, 465, 
509 
paralysis, 466 
treatment of, 467 
st3*loid process. 485 

treatment of, 487 
Ulnar nerye, landmarks in elbow injuries, 

493 
Unreduced dislocation, patholog}^ of 
bone, 171 
treatment of, 181 
use of roentgenogram in, 172 
Ununited fractures, 77, 154 
treatment of, 154 
Upward clavicular dislocations, 308 
Urethral rupture in pelvic fracture, 575 
treatment of, 579 



Velpeau's bandage, 298 
Vertebrae, cervical, fracture of, 660 
displacement of, 262 
examination of, 261 
mechanism of, 262 
m^'ehtis, 261 
symptoms of, 261 
fracture-dislocation of, reduc- 
tion bj' manipulation, 
269 
treatment of, 269 
operative, 270 
dorsal, fracture-dislocation of, 270 
effects of laminectomy on, 

272 
pathology of, 270 
prognosis of, 273 
symptoms and diagnosis 
of, 271, 273 
fracture of arches, 249 

articular processes, 251 

rib fracture in connec- 
tion with, 251 
causes, 254 

cord hemorrhage in, 254 
diagnosis of, 258 
and dislocations of, 243 
anatomy of, 243 



Vertebra:, fracture and dislocations of, 
causes of, 244 
compression in, 248 
displacements in, 246, 259 
intervertebral cartilage in, 

249 
medullary canal in, 247, 

248 
occurrence of, 244 
pathology of, 244, 245 
statistics of, 244 
hemiplegia, 256 
jack-knife mechanism in, 254 
lumbar puncture in, 260 
paralysis following, 259 
spinal fluid in, 260 
spinous processes, 254 
symptoms of, 253, 258 
abdominal, 253 
simulating appendicitis, 
253 
of transverse processes, 251 
treatment of, general, 279 

operative, 280 
use of roentgenogram in, 252, 
260 
gunshot injuries of, 283 
lumbar, fracture-dislocation of, 274 
arches, 276 
body, 276 
cord injury in, 277 
excess callus in, 276 
hematomyelia in, 277 
prognosis of, 275 
pseudarthrosis in, 276 
spinous processes, 276 
symptoms of, 274 
transverse processes, 276 
treatment of, 275 
Vessel mjury in upper humeral fractures, 

380 
Vicious union of callus, 85 
Visceral injuries in dislocation, 166 
Vocal cord involvement of, in tracheal 

injuries, 351 
Volkmann's ischemic contraction, 69 
in forearm fractures, 459 
in fracture of shaft of 

humerus, 384 
pathology of, 69 
symptoms of, 70 
treatment of, 70 
sliding splint, 116 
Voluntary dislocation, 162 
Vomiting in sternal fractures, 348 
Vorshiitz's sign, in fracture of lesser 
trochanter of femur, 635 



W 



Walton's operative indication for in- 
ternal splints, 143 

Weight-bearing influence on bone heal- 
ing, 136 

Wire sj)lints, 116 



888 



INDEX 



Wire, use of, in fracture of clavicle, 303 
Wiring in acromioclavicular dislocations, 
317 
jaw, feeding, 232 

nasal feeding, 232 
postanesthetic vomiting, 231 
teeth, 229, 230 

Angle's method of, 230 
Angvvine's method of, 230 
Loher's splint in, 232 
in maxillary fractUnres, 221 
Wolff's law applied to non-union of 
calhis, 83 
to reduction of fracture, 
100 



Wolff's law of fat embolism, 64 

applied to postural 
changes in bone, 68 
in unreduced dislocation, 171 
Wood's frame, 212 

Wrist bones, dislocations of, classification 
of, 537 
pathology of, 545 
joint, normal motions in, 522 



Y-LIGAMENT, 

tions of. 



670. See Hip, disloca- 



/p 



AV~ ■'^.. 






"■>..'. 






^ ^ ^^^' •^- >^ ^^- %^ '^bo^ ; 



5- ^ 






•>^i 









'/ 



o. 



"oo^ 



"^.s^ 






•-^' 









"^"^ 



0^ 






"^A V^ 



.^■^^ ~^' 



-*^ V^' 






.0' 



^^-'^^ 



<. 




"oo^ 



'"^^ 



^^. 






' / 



"^/> 4 



A^^"v <= 



^^^:: 



^" .ci- 




xQ<^.. 



^^ 



.'s-' 






J. ^ 



-^^ %;^^> ^v 



, k ^- ,o 



^ ^ 



■0' 






.0 0. 



^ .0- 



'K 






^0^ 



'^, .-^^ 



v^^ "^.. 



^v 



/■ v\^ 



5^ r"! 












/ > 






'-% 






<y <^^ 






-f-. i^ 



^-e^ 



^ ^ » ft ^ \ ^ , , 



^ >.V 






A^^ . ■i^I^X'-^ 






v^''^*^^^^'' 



oo^ 









Sso^ 












%-%'=' 












e^ "7*/ 



'. ' ^^ v^^ 






.^- 






v*-' -^"-^ 






^o ' ;--^ o ,^ 



^^^' 



>>r^>^'^\o\^i:i^^^' 












,•0' 









-r 



\' * 












•^. ,,nV 



.,0 C 













"' -co' 


./ 


.>^ •'*- 


. >^ 



LIBRARY OF CONGRESS 



021 068 919 9 



r »' K ,,♦ 



1: 'I » It 1 > 



^ ?7J 'f'0*^'» 



/- .1 * n m" ' i 



'X '^ / <Ai 



«; 



!'//^l' 



-.Y^, 



f ' 






M,^j,.' 



^) >' 



i"ir 



•i»il 






> ( 



t f 








M ^*<J 


\ * 


. *'iii.i 


'' f 


^ r"ii' 


' / 1 

1 \ >\' <"{ 


^*!ur' 


, i\ ' 


1 . • V ^-'^ 


,1 I ' 


' >i'V 






'-'','* .^ .. ,' ' ; '^s^■ 



< V >' c 



,1^ 



i<y 






H. " r <♦ , 









v- '-.• 









